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Background Opioid overuse is a costly and significant problem in the United States. Medical specialties including surgery are a contributor to opioid prescriptions while having few clear prescribing guidelines. Machine learning predictive tools can assist surgeons with evaluating patients for opioid prescriptions and help prevent prescriptions for patients at-risk for prolonged post-operative opioid use. This project aims to develop accurate and transparent machine learning models to predict prolonged opioid use by individuals undergoing rotator cuff surgery. Methods Six machine learning models were trained on a dataset of 852 individuals undergoing rotator cuff surgery and evaluated for predictive accuracy. Machine learning explainability techniques were used to improve model transparency, including Shapley Additive explanations (SHAP) for global variable importance and local interpretable model-agnostic explanations (LIME) for local variable effects and importance. Results Four of six machine learning models developed had predictive accuracy greater than 0.71, with our top three models having an accuracy of 0.98 (XGBoost), 0.94 (Random Forest), and 0.74 (Decision Tree). SHAP and LIME explanations were created for models allowing insight and interpretation into model outputs. Conclusion We were able to develop predictive machine learning models that displayed predictive accuracy in predicting prolonged post-operative opioid use while improving model explainability and transparency.

Background: Recurrent anterior shoulder instability after arthroscopic Bankart repair presents a challenging clinical problem, with the primary stabilization procedure often portending the best chance for clinical success. Purpose: To determine if capsuloligamentous laxity affects failure (recurrent dislocation, subluxation, and/or perceived instability symptoms) after arthroscopic Bankart repair in patients with near-track lesions (ie, those with smaller distance to dislocation [DTD]). Study Design: Case-control study; Level of evidence, 3. Methods: The authors retrospectively reviewed consecutive patients who underwent primary arthroscopic Bankart repair for recurrent anterior glenohumeral instability at a single institution between 2007 and 2019 and who had at least 2 years of follow-up data. Patients with glenoid bone loss >20%, off-track lesions, concomitant remplissage, or rotator cuff tear were excluded. Capsuloligamentous laxity, or hyperlaxity, was defined as external rotation >85° with the arm at the side and/or grade ≥2 in at least 2 planes with the shoulder at 90° of abduction. Near-track lesions were defined as those with a DTD <10 mm. Results: Included were 173 patients (mean age, 20.5 years; mean DTD, 16.2 mm), of whom 16.8% sustained a recurrent dislocation and 6.4% had recurrent subluxations (defined as any subjective complaint of recurrent instability without frank dislocation), for an overall recurrent instability rate of 23.1%. The rate of revision stabilization was 15.6%. The mean time to follow-up was 7.4 years. Independent predictors of recurrent instability were younger age (P = .001), smaller DTD (P = .021), >1 preoperative instability episode (P < .001), and the presence of hyperlaxity during examination under anesthesia (P = .013). Among patients with near-track lesions, those with hyperlaxity had a recurrent instability rate almost double that of patients without hyperlaxity (odds ratio, 34.1; P = .04). The increased rate of failure and recurrent dislocation in the near-track hyperlaxity cohort remained elevated, even in patients with no bone loss. Conclusion: Capsuloligamentous shoulder laxity was a significant independent risk factor for failure after primary arthroscopic Bankart repair without remplissage and was more predictive of failure in patients with versus without near-track lesions.

Objectives: Anecdotally, weight-bearing status following hip arthroscopy is gradual and requires 2-6 weeks of protected weight bearing. In a recent cadaveric study, it was demonstrated that a repaired acetabular labrum can handle physiological loads of weight bearing. Therefore, it is hypothesized that allowing patients to be immediately weight-bearing as tolerated (WBAT) may allow them to have reduced kinesiophobia and expedited return to activities of daily living compared to the current standard of care of 2 weeks of flat-foot weight bearing (FFWB). This quicker return to normal activities would allow them to benefit from advanced therapeutic interventions leading to improved short and longer term post-operative results. The objective of this study is to assess the effectiveness of advancing weight bearing immediately following hip arthroscopic labral repair and femoroplasty as it relates to short term pain, function, and long-term return to activities. This abstract is a presentation of our initial pilot data. Methods: This study received IRB approval at the University of Pittsburgh. Study design was a prospective randomized controlled trial (Level 1). Inclusion criteria included all patients over 12 years of age who presented for hip arthroscopy, including labral repair and femoroplasty at UPMC St. Margaret Hospital Hip Preservation Program. Surgical management was performed by a single surgeon at a single center. The single surgeon was blinded to randomization. No exclusions based on patient sex, race, or other demographics. Revision hip arthroscopy, labral reconstruction, and microfracture of cartilage defects were excluded. Two separate protocols were created to indicate weight bearing status, either WBAT immediately post-operatively or FFWB immediately post-operatively, to distribute to rehabilitation staff to ensure compliance. A randomized pamphlet with post-operative instructions with weight bearing education were given to PACU nursing staff to educate patients and fit crutches. Both groups received standard of care, including physical therapy starting either day one or two post-operative to implement passive range of motion and peri-hip musculature activation. All patients had precautions protecting from hip extension past 0 degrees and external rotation of the hip to protect healing of the joint capsule. Patients completed patient reported outcomes (PROs) pre-operatively, followed by 1 week, 3 months, 6 months, 9 months, 1 year and 2 years post-operatively. Objective data will include quadriceps girth measurements, dynamometric hip abduction and external rotation strength measures at 6 months and 1-year post-operative. Diagnostic ultrasound evaluation of the joint capsule was performed by a PM&R physician at 6 weeks post-operatively to ensure that capsular repair was healing appropriately in both groups. PM&R staff were blinded to the weight bearing group. PROs included: Tampa Kinesiophobia Scale, Hip Outcome Score (HOS), Hip and Groin Outcome Score (HAGOS), iHOT-12, Modified Harris Hip Score, Subjective hip satisfaction score/global rating of improvement. Overall recruitment goal of 40 patients in each group. The collected data will allow us to review overall function, objective measures, and return to desired activity/athletics, as well as determine the effectiveness of progressive weight bearing following hip arthroscopy, labral repair, and femoroplasty. Results: A total of 14 patients were randomized to WBAT and 10 patients randomized to FFWB. No patients were excluded. The 6-week capsule assessment by ultrasound showed a well approximated capsule repair site in 23 of 24 patients. The one patient with a potential capsular defect was in the WBAT group. Ultrasound demonstrated a 6mm x 6mm anechoic finding in the anterior capsule concerning for focal capsular defect. Tampa Kinesiophobia Scale and Modified Harris Hip Score were compared between groups at 2 weeks and 3 months post-operatively in our initial sample using a two-sample t-test with equal variances. No statistically significant difference was observed between groups at 2 weeks and 3 months. Conclusions: In summarizing our initial data, no statistically significant differences were observed in the immediate weight bearing and delayed weight bearing groups in terms of Tampa Kinesiophobia Scale and Modified Harris Hip Score at 2 weeks and 3 months post-operatively. One patient showed a potential capsular defect on ultrasound at 6 weeks in the WBAT group. No complications have been observed thus far in our pilot sample.

Background: The corrective procedures for meniscal injury are dependent on tear type, severity, and location. Vertical longitudinal tears are common in young and active individuals, but their natural progression and impact on osteoarthritis (OA) development are not known. Root tears are challenging and they often indicate poor outcomes, although the timing and mechanisms of initiation of joint dysfunction are poorly understood, particularly in large-animal and human models. Purpose/Hypothesis: In this study, vertical longitudinal and root tears were made in a large-animal model to determine the progression of joint-wide dysfunction. We hypothesized that OA onset and progression would depend on the extent of injury-based load disruption in the tissue, such that root tears would cause earlier and more severe changes to the joint. Study Design: Controlled laboratory study. Methods: Sham surgeries and procedures to create either vertical longitudinal or root tears were performed in juvenile Yucatan mini pigs through randomized and bilateral arthroscopic procedures. Animals were sacrificed at 1, 3, or 6 months after injury and assessed at the joint and tissue level for evidence of OA. Functional measures of joint load transfer, cartilage indentation mechanics, and meniscal tensile properties were performed, as well as histological evaluation of the cartilage, meniscus, and synovium. Results: Outcomes suggested a progressive and sustained degeneration of the knee joint and meniscus after root tear, as evidenced by histological analysis of the cartilage and meniscus. This occurred in spite of spontaneous reattachment of the root, suggesting that this reattachment did not fully restore the function of the native attachment. In contrast, the vertical longitudinal tear did not cause significant changes to the joint, with only mild differences compared with sham surgery at the 6-month time point. Conclusion: Given that the root tear, which severs circumferential connectivity and load transfer, caused more intense OA compared with the circumferentially stable vertical longitudinal tear, our findings suggest that without timely and mechanically competent fixation, root tears may cause irreversible joint damage. Clinical Relevance: More generally, this new model can serve as a test bed for experimental surgical, scaffold-based, and small molecule–driven interventions after injury to prevent OA progression.

Background: Despite increasing use of quadriceps tendon (QT) autograft in anterior cruciate ligament (ACL) reconstruction (ACLR), limited data exist regarding its outcomes in high-risk adolescent athletes. Purpose: To (1) report the outcomes after QT ACLR in adolescent athletes and (2) identify patient-related and surgery-related factors that may influence failure rates after QT ACLR. Study Design: Case series; Level of evidence, 4. Methods: All patients aged 14 to 17 years who underwent primary anatomic, transphyseal, single-bundle QT ACLR between 2010 and 2021 with a minimum 2-year follow-up were included for analysis. Demographic and surgical data as well as preoperative International Knee Documentation Committee (IKDC) and Marx activity scores were collected retrospectively. All patients were also contacted to assess postoperative patient-reported outcomes (PROs), including IKDC and Marx activity scores, and return-to-sports (RTS) data. Outcomes of interest included rates of revision ACLR and ipsilateral complications, contralateral ACL tears, difference in pre- and postoperative PROs, and rates of RTS. Patient and surgical characteristics were compared between groups who required revision ACLR versus those who did not. Results: A total of 162 patients met inclusion criteria, of which 89 adolescent athletes (mean age 16.2 ± 1.1 years, 64% female) were included for analysis at mean follow-up of 4.0 years. Postoperative IKDC scores were significantly higher than preoperative scores (88.5 vs 37.5; P < .001), whereas Marx activity scores decreased postoperatively (14.3 vs 12.2; P = .011). Successful RTS occurred in 80% of patients at a mean time of 9.7 ± 6.9 months, and 85% of these patients returned to the same or higher level of sports. The most common reasons for failure to RTS included lack of time (n = 7, 70%) and fearing reinjury in the operative knee (n = 5, 50%). The overall revision ACLR rate was 10% (n = 9), and contralateral ACL tears occurred in 14% (n = 12) of patients. The overall ipsilateral knee reoperation rate was 22.5% (n = 20). No statistically significant differences in patient or surgical characteristics were observed between patients who underwent revision ACLR and those who did not. Conclusion: At a minimum 2-year follow-up after QT ACLR, adolescent athletes experienced significantly improved postoperative IKDC scores, high rates of RTS, and low rates of graft failure, despite a relatively high ipsilateral reoperation rate. Surgeons may utilize this information when identifying the optimal graft choice for adolescent athletes who have sustained an ACL injury and wish to return to high level of sporting activities.

•We determined the incidence of headache in surgical patients with sellar lesions.•Risk factors for headache include pathology, younger age, and female gender.•Rate of improvement of headache after surgery is identified.•Complete resection or shorter headache duration were associated with improvement. Due to the high incidence of headaches and pituitary tumors, neurosurgeons often evaluate patients with benign-appearing sellar lesions and headaches without insight into whether the headache is attributable to the lesion. We sought to evaluate the incidence of headache as a presenting complaint in patients undergoing transsphenoidal surgery for various pathologies and to identify factors predicting postoperative improvement. We conducted a 5-year retrospective review of our first 1015 transsphenoidal surgeries since establishing a dedicated pituitary center. Of 1015 patients, 329 (32%) presented with headache. Of these 329 patients, 241 (73)% had headache as their chief complaint. Headache was most common in patients with apoplexy (84%), followed by Rathke's cleft cysts (RCCs) (60%). Multivariate analyses revealed diagnosis (P=0.001), younger age (P=0.001), and female gender (P=0.006) to be associated with headache. Of patients presenting with headaches, 11% reported improvement at 6-week follow-up and 53% improved at 6-month follow-up. Multivariate analyses revealed gross total resection (GTR; P=0.04) and decreased duration of headache (P=0.04) to be associated with improvement, while diagnosis, age, gender, lesion size, whether headache was a chief complaint, and location of headache were not associated with improvement (P>0.05). In analyzing over 1000 consecutive patients undergoing transsphenoidal surgery, younger patients, females, and patients with RCCs and apoplexy were more likely to present with headache. Patients who underwent GTR and had shorter duration of headache were more likely to experience headache improvement. This information can be used to counsel patients preoperatively.

Background: There is no standard method for the surgical treatment of acromioclavicular (AC) joint separations. Current techniques have associated complications, including need for device removal, coracoid fracture, and inadequate reduction. Purpose: To evaluate the clinical outcomes of an internal splint technique without graft augmentation or rigid fixation to treat acute Rockwood type IV and V AC joint injuries. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis was performed of 26 patients who underwent a novel internal splint fixation technique between 2011 and 2016. Patients had type IV (n = 2) and type V (n = 24) acute AC separations. The mean time to surgery was 13.7 days (range, 1-28 days). The surgical technique included an open approach with coracoclavicular suture and tape fixation and AC suture fixation. Range of motion, strength, and radiographs were evaluated after surgery. Patient follow-up included the DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire at a mean 3.3 years postoperatively (range, 6 months–8.6 years). DASH questionnaires were obtained for all patients via email. Patients were also surveyed on cosmetic appearance and willingness to undergo the operation again. Results: All patients regained full strength and range of motion following surgery. All postoperative radiographs demonstrated well-maintained reduction of the AC joint. The mean DASH score was 3.4 at final follow-up, and 23 of 26 respondents were satisfied with their postoperative shoulder appearance. There were no reoperations, and all patients stated that they would have the operation again given the same circumstances. Conclusion: The results of this study demonstrate a reliable new technique for acute fixation of type IV or V AC joint injuries via an internal splint construct. This technique enables reduction in the coronal and sagittal planes without the need for graft augmentation or a rigid implant, allowing healing of the coracoclavicular and AC ligaments.

Background Adult tibial spine fractures (TSFs) are rare but can cause significant morbidity. Materials and Methods A systematic review identified studies on adult TSFs. Patient demographics, fracture characteristics, surgical details, outcomes, and complications were analyzed using descriptive statistics and meta-analysis. Results Twenty-eight studies (691 cases) were included. Most fractures were type III, treated arthroscopically with sutures or screws. Fracture type showed no significant differences in outcomes. Suture fixation yielded better functional scores and fewer complications than screws. Conclusion No definitive advantage was observed for either fracture type or fixation method. Further research is needed to establish optimal treatments. [Orthopedics. 2025;48(3):174–187.]

Advances in arthroscopic methods have provided significant improvements in visualization, characterization, and repair techniques of rotator cuff tears. However, the treatment of massive, retracted tears continues to pre sent a challenge. Although the most common individual tear pattern reportedly is of the crescent-shaped variety, most tears possess at least one mobile limb and require a side-to-side reduction due to the very narrow lateral width of the supraspinatus insertion, shown to be only 1.3 mm. 1 The infraspinatus tendon has been shown to insert anteriorly on the greater tuberosity as it blends with the supraspinatus footprint (Figure 6-1). Thus, tears with an exposed lateral footprint greater than 1.3 mm will usually require some mobilization to allow excursion infraspinatus tissue anteriorly or coracohumeral ligament tissue posteriorly. Crescent tears (Figure 6-2) that are repaired directly laterally with double-row constructs are usually malreduced and will predictably undergo excessive tension at the bone tendon junction (Figure 6-3). Massive cuff tears, which have a reported prevalence of nearly 40%, would be logically expected to pre sent a mobile limb, either anteriorly or posteriorly, in essentially all cases. 1 Tension is the bane of rotator cuff repair, 2 and it is the senior author's contention that in an effort to obtain a double-row construct, the art of tear reduction has been lost.