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Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Growing evidence suggests addressing posterior malleolus fractures in trimalleolar ankle fractures may enhance syndesmotic stability. However, syndesmosis open reduction internal fixation (ORIF) encounters various challenges, particularly malreduction, rendering it an imperfect procedure. This study aims to evaluate contemporary practices in the treatment of trimalleolar fractures, assessing whether there is a rising trend in posterior malleolus fixation alongside a decline in subsequent syndesmotic repair. Methods: A retrospective cohort analysis of the PearlDiver (Mariner dataset) database from 2010-2021 was performed for patients undergoing trimalleolar ORIF and stratified by posterior lip fixation status. Annual percentage incidence of syndesmotic repair within these cohorts was tabulated and compound annual growth rate (CAGR) and Mann Kendall analysis was performed to assess trends. Characteristics associated with posterior lip fixation were analyzed with χ2 analysis. Results: From 2010-2021, there was an increase in the incidence of concomitant posterior malleolus fixation in trimalleolar ORIF from 17.6% to 21.4% (CAGR: +6.2%, Mann Kendall p-value: 0.011). The incidence of trimalleolar ORIF without posterior fixation decreased from 82.4% to 78.6% (CAGR: -3.0%, Mann Kendall p-value: 0.04). The incidence of syndesmotic repair following trimalleolar fixation increased from 10.1% to 29.3% (CAGR for posterior fixation: +17.0%, Mann Kendall p-value: < 0.001; CAGR for no posterior fixation: +13.1%, Mann Kendall p-value: < 0.001). Trimalleolar ORIF with posterior fixation demonstrated similar rates of malunion, nonunion, and reoperation at two-years postoperative, with no significant differences on χ2 analysis, compared to those without posterior malleolus fixation. Conclusion: The incidence of trimalleolar ORIF with posterior lip fixation has increased over the past decade. Contrary to our hypothesis, the rate of subsequent syndesmotic repair following trimalleolar ORIF increased, potentially due to the heightened recognition of the importance of syndesmotic stability. Future randomized control studies may further evaluate the effect of posterior lip fixation on syndesmotic stability.

Background: There is currently no consensus on immobilization protocols following shoulder surgery. The aim of this study was to establish patterns and types of sling use for various surgical procedures in the United States (US) and Europe, and to identify factors associated with the variations. Methods: An online survey was sent to all members of the American Shoulder and Elbow Society (ASES) and European Society for Surgery of the Shoulder and Elbow (ESSSE). The survey gathered member data, including practice location and years in practice. It also obtained preferences for the type and duration of sling use after the following surgical procedures: arthroscopic Bankart repair, Latarjet, arthroscopic superior/posterosuperior rotator cuff repair (ARCR) of tears <3 cm and >3 cm, anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA), and isolated biceps tenodesis (BT). Relationships between physician location and sling type for each procedure were analyzed using Fisher’s exact tests and post-hoc tests using Bonferroni-adjusted p-values. Relationships looking at years in practice and sling duration preferred were analyzed using Spearman’s correlation tests. Results: In total, 499 surgeons with a median of 15 years of experience (IQR = 9–25) responded, with 54.7% from the US and 45.3% from Europe. US respondents reported higher abduction pillow sling use than European respondents for the following: Bankart repair (62% vs. 15%, p < 0.0001), Latarjet (53% vs. 12%, p < 0.001), ARCR < 3 cm (80% vs. 42%, p < 0.001) and >3 cm (84% vs. 61%, p < 0.001), aTSA (50% vs. 21%, p < 0.001) and rTSA with subscapularis repair (61% vs. 22%, p < 0.001) and without subscapularis repair (57% vs. 17%, p < 0.001), and isolated BT (18% vs. 7%, p = 0.006). European respondents reported higher simple sling use than US respondents for the following: Bankart repair (74% vs. 31%, p < 0.001), Latarjet (78% vs. 44%, p < 0.001), ARCR < 3 cm (50% vs. 17%, p < 0.001) and >3 cm (34% vs. 13%, p < 0.001), and aTSA (69% vs. 41%, p < 0.001) and rTSA with subscapularis repair (70% vs. 35%, p < 0.001) and without subscapularis repair (73% vs. 39%, p < 0.001). Increasing years of experience demonstrated a negative correlation with the duration of sling use after Bankart repair (r = −0.20, p < 0.001), Latarjet (r = −0.25, p < 0.001), ARCR < 3 cm (r = −0.14, p = 0.014) and >3 cm (r = −0.20, p < 0.002), and aTSA (r = −0.37, p < 0.001), and rTSA with subscapularis repair (r = −0.10, p = 0.049) and without subscapularis repair (r = −0.19, p = 0.022. Thus, the more experienced surgeons tended to recommend shorter durations of post-operative sling use. US surgeons reported longer post-operative sling durations for Bankart repair (4.8 vs. 4.1 weeks, p < 0.001), Latarjet (4.6 vs. 3.6 weeks, p < 0.001), ARCR < 3 cm (5.2 vs. 4.5 weeks p < 0.001) and >3 cm (5.9 vs. 5.1 weeks, p < 0.001), aTSA (4.9 vs. 4.3 weeks, p < 0.001), rTSR without subscapularis repair (4.0 vs. 3.6 weeks, p = 0.031), and isolated BT (3.7 vs. 3.3 weeks, p = 0.012) than Europe respondents. No significant differences between regions within the US and Europe were demonstrated. Conclusions: There is considerable variation in the immobilization advocated by surgeons, with geographic location and years of clinical experience influencing patterns of sling use. Future work is required to establish the most clinically beneficial protocols for immobilization following shoulder surgery. Level of Evidence: Level IV.

Objectives: An abundance of literature exists demonstrating the link between eating disorders and fracture risk. However, no studies to our knowledge have investigated the impact of an eating disorder diagnosis on risk for ligamentous injury or the need subsequent orthopedic surgery. The aim of this study was therefore to elucidate this link and determine if pre-existing eating disorder diagnoses are associated with increased incidence of lower extremity connective tissue-related orthopaedic injuries and surgeries. We hypothesized that eating disorders, specifically anorexia nervosa and bulimia nervosa, lead to an increased risk of ligamentous injuries and need for surgery on injured ligaments. Methods: Patients with a diagnosis of anorexia nervosa or bulimia nervosa were identified using International Classification of Diseases (ICD) -9 and -10 codes using the PearlDiver Mariner insurance claims data set. These patients were matched by age, gender, Charlson Comorbidity Index, record dates, and geographical region to respective control groups without anorexia nervosa or bulimia nervosa. Instances of ligamentous injuries were identified through ICD-9 and ICD-10 codes within the time period of 2010-2020 available within the Mariner dataset. Instances of ligamentous orthopaedic surgery procedures in these patients were identified through Current Procedural Terminology (CPT) codes. Rates of ligamentous injury and orthopaedic surgery among experimental and control cohorts were analyzed using chi-squared analysis. Results: The anorexia nervosa cohort and its matched control group contained a total of 2,475 patients each. Patients with a diagnosis of anorexia nervosa were significantly more likely to sustain a meniscus tear (RR=1.57, p=0.001) or deltoid ligament sprain (RR=1.83, p=0.025), and to undergo anterior cruciate ligament (ACL) reconstruction (RR=2.83, p=0.037). They were less likely to sustain a tibiofibular ligament sprain (RR=0.64, p=0.012). The bulimia nervosa cohort and its matched control group contained a total of 2,375 patients each. Patients with a diagnosis of bulimia nervosa were significantly more likely to sustain a meniscus tear (RR=1.98, p <0.001), medial collateral ligament (MCL) sprain (RR=3.07, p<0.001), any cruciate ligament tear (RR=2.14, p=0.004), unspecified ankle sprain (RR=1.56, p<0.001), and any ankle ligament sprain (RR=1.27, p=0.008), and to undergo partial meniscectomy (RR=1.80, p=0.002). Conclusions: Diagnosis of an eating disorder is associated with an increased risk of certain ankle and knee ligamentous injuries and surgeries. Orthopaedic surgeons should be aware of the effects these disorders have on soft tissue injury and surgery rates. Furthermore, patients presenting to orthopaedic surgery clinics should be informed of increased risks associated with their eating disorder diagnoses and provided with information on resources promoting recovery to help prevent further injury.

Background Unicompartmental knee arthroplasty (UKA) is a surgical treatment for knee osteoarthritis associated with lower morbidity compared with total knee arthroplasty (TKA) in patients with isolated unicompartmental knee arthritis. As disparities have been noted broadly in arthroplasty care, it follows that such disparities might be present in the utilization of UKA relative to TKA. This study therefore examined racial/ethnic, socioeconomic, and payer status differences in utilization of UKA. Methods Patients who underwent UKA or TKA between 2016 and 2020 in the National Inpatient Sample were identified. Multivariable Poisson regression models adjusted for hospital geographic region and patient characteristics [age, sex, and Elixhauser Comorbidity Index (ECI)] were used to examine the effect of race/ethnicity, socioeconomic status, and payer status on incidence rate ratio of UKA relative to TKA. Results Of the 8472 UKA patients and 639,937 TKA patients identified between 2016 and 2020, 8027 (94.7%) UKA patients and 606,028 (94.7%) TKA patients met inclusion criteria. Patients who underwent UKA were significantly younger (63.5 ± 10.7 years) than patients who underwent TKA (66.8 ± 9.5 years; p < 0.001) and had significantly lower ECI scores (1.8 ± 1.5) than patients who underwent TKA (2.2 ± 1.6; p  < 0.001). Black patients were less likely to undergo UKA relative to TKA compared with white patients [incidence rate ratio (IRR) 0.64, confidence interval (CI) 0.58–0.71, p  < 0.001]. Compared with patients in income quartile 4, patients in income quartiles 1 and 2 underwent UKA at a lower relative rate (IRR 0.85, CI 0.79–0.90, p  < 0.001 and IRR 0.87, CI 0.82–0.93, p  < 0.001, respectively). Compared with patients with private insurance, patients with Medicare underwent UKA at a lower relative rate (IRR 0.83, CI 0.79–0.88, p  < 0.001). Conclusions Black patients, lower-income patients, and Medicare-insured patients undergo UKA at a lower relative rate than white, higher-income, and privately insured patients, respectively. Further research may help elucidate reasons for these differences and identify targets for intervention.

Background Body mass index (BMI) has been shown to influence risk for revision total hip arthroplasty (rTHA), but few studies have specifically examined which causes of rTHA are most likely in different BMI classes. We hypothesized that patients in different BMI classes would undergo rTHA for disparate reasons. Methods Ninety-eight thousand six hundred seventy patients undergoing rTHA over 2006–2020 were identified in the National Inpatient Sample. Patients were classified as underweight, normal-weight, overweight/obese, or morbidly obese. Multivariable logistic regression was used to analyze the impact of BMI on rTHA for periprosthetic joint infection (PJI), dislocation, periprosthetic fracture (PPF), aseptic loosening, or mechanical complications. Analyses were adjusted for age, sex, race/ethnicity, socioeconomic status, insurance, geographic region, and comorbidities. Results Compared to normal-weight patients, underweight patients were 131% more likely to have a revision due to dislocation and 63% more likely due to PPF. Overweight/obese patients were 19% less likely to have a revision due to dislocation and 10% more likely due to PJI. Cause for revision in morbidly obese patients was 4s1% less likely to be due to dislocation, 8% less likely due to mechanical complications, and 90% more likely due to PJI. Conclusions Overweight/obese and morbidly obese patients were more likely to undergo rTHA for PJI and less likely for mechanical reasons compared to normal weight patients. Underweight patients were more likely to undergo rTHA for dislocation or PPF. Understanding the differences in cause for rTHA among the BMI classes can aid in patient-specific optimization and management to reduce postoperative complications. Level of evidence III.

A reader-friendly overview of fundamentals in shoulder pathology and treatment from renowned experts! Shoulder problems comprise a significant percentage of orthopaedic practice, including trauma and sports related injuries. Synopsis of Shoulder Surgery by Uma Srikumaran and esteemed contributors provides a concise, well-rounded perspective on the surgical and nonsurgical management of a wide array of shoulder disorders. The opening chapters lay a solid foundation of knowledge, covering anatomy, physical examination of the shoulder, surgical approaches to the shoulder, imaging, and the use of diagnostic and therapeutic injections. Subsequent chapters succinctly discuss management of a comprehensive range of shoulder conditions, organized by the underlying type of pathology. The final chapters provide insightful pearls on shoulder rehabilitation and perioperative pain management. Key Features * Concise summaries of common shoulder pathologies and treatment options * Discussion of core procedures for rotator cuff disease, frozen shoulder, instability, osteoarthritis, clavicle and proximal humerus fractures, and thoracic outlet syndrome * The easy-to-digest bulleted format and wealth of illustrations enhance understanding of diverse shoulder problems and techniques * Succinct presentation allows for quick review and use for board examination preparation This is a must-have resource for orthopedic surgeons in training and advanced allied health personnel. Shoulder surgeons, physician assistants, and front line providers such as primary care and emergency room physicians will also find this book to be a useful resource.

Technological innovation is a key component of orthopedic surgery. Artificial intelligence (AI), which describes the ability of computers to process massive data and “learn” from it to produce outputs that mirror human cognition and problem solving, may become an important tool for orthopedic surgeons in the future. AI may be able to improve decision making, both clinically and surgically, via integrating additional data-driven problem solving into practice. The aim of this article will be to review the current applications of AI in the management of rotator cuff tears. The article will discuss various stages of the clinical course: predictive models and prognosis, diagnosis, intraoperative applications, and postoperative care and rehabilitation. Throughout the article, which is a review in terms of study design, we will introduce the concept of AI in rotator cuff tears and provide examples of how these tools can impact clinical practice and patient care. Though many advancements in AI have been made regarding evaluating rotator cuff tears—particularly in the realm of diagnostic imaging—further advancements are required before they become a regular facet of daily clinical practice.

Summary Patients who sustain fragility fractures prior to total shoulder arthroplasty have significantly higher risk for bone health-related complications within 8 years of procedure. Identification of these high-risk patients with an emphasis on preoperative, intraoperative, and postoperative bone health optimization may help minimize these preventable complications. Purpose As the population ages, more patients with osteoporosis are undergoing total shoulder arthroplasty (TSA), including those who have sustained a prior fragility fracture. Sustaining a fragility fracture before TSA has been associated with increased risk of short-term revision rates, periprosthetic fracture (PPF), and secondary fragility fractures but long-term implant survivorship in this patient population is unknown. Therefore, the purpose of this study was to characterize the association of prior fragility fractures with 8-year risks of revision TSA, periprosthetic fracture, and secondary fragility fracture. Methods Patients aged 50 years and older who underwent TSA were identified in a large national database. Patients were stratified based on whether they sustained a fragility fracture within 3 years prior to TSA. Patients who had a prior fragility fracture (7631) were matched 1:1 to patients who did not based on age, gender, Charlson Comorbidity Index (CCI), smoking, obesity, diabetes mellitus, and alcohol use. Kaplan–Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences of all-cause revision, periprosthetic fracture, and secondary fragility fracture within 8 years of index surgery. Results The 8-year cumulative incidence of revision TSA (5.7% vs. 4.1%), periprosthetic fracture (3.8% vs. 1.4%), and secondary fragility fracture (46.5% vs. 10.1%) were significantly higher for those who had a prior fragility fracture when compared to those who did not. On multivariable analysis, a prior fragility fracture was associated with higher risks of revision (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.24–1.74; p  < 0.001), periprosthetic fracture (HR, 2.98; 95% CI, 2.18–4.07; p  < 0.001) and secondary fragility fracture (HR, 8.39; 95% CI, 7.62–9.24; p  < 0.001). Conclusions Prior fragility fracture was a significant risk factor for revision, periprosthetic fracture, and secondary fragility fracture within 8 years of primary TSA. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications. Level of Evidence : III.