Purpose Traumatic anterior instability of the shoulder is a common condition associated with a high recurrence rate in young patients. The role of nonoperative versus operative treatment and the ...optimal surgical approach for this condition is debated. The purpose of this study was to review the literature for the latest evidence comparing outcomes of treatment for traumatic anterior instability of the shoulder. Methods A systematic review of the literature was performed to identify studies comparing operative versus nonoperative treatment for traumatic anterior shoulder instability and studies comparing open versus arthroscopic stabilization for traumatic anterior shoulder instability. Results Surgical treatment was associated with a significantly lower rate of recurrent instability at 2 years of follow-up (7% v 46%) and at longer-term follow-up (10% v 58%) for first-time traumatic anterior shoulder dislocation, all in younger patients. The rates of recurrent instability were roughly equal after arthroscopic stabilization with suture anchors and open stabilization with anchors (open, 8.2%; arthroscopic, 6.4%). Conclusions Rates of recurrent instability after a first-time anterior shoulder dislocation, particularly in young active male patients, are reduced by surgical intervention compared with nonoperative treatment. If surgical treatment is indicated, an arthroscopic approach using suture anchors appears to have similar results in terms of recurrent instability to an open approach using suture anchors.
Purpose
To evaluate the rate at which children and adolescent athletes return to sporting activities after anterior cruciate ligament (ACL) reconstruction.
Methods
Three databases, PubMed, MEDLINE, ...and EMBASE, were searched from database inception until September 9, 2017 by two reviewers independently and in duplicate. The inclusion criteria were English language studies that reported return to sport outcomes. Book chapters, conference papers, review articles, and technical reports were excluded. The rate of return to sports was combined in a meta-analysis of proportions using a random-effects model.
Results
Overall, 20 studies with a combined total of 1156 ACL reconstructions met the inclusion criteria, with a mean age of 14.3 years (range 6–19) and a mean follow-up time of 6.5 years (range 1–22). All studies were level IV evidence (14 retrospective case series and 6 prospective case series). The pooled rate of return to any sport participation was 92.0% 95% confidence interval (CI), 86–96%. The pooled rate of return to pre-injury level of sport was 78.6% (95% CI 71–86%) and that to competitive level of sport was 81.0% (95% CI 62–94%). A total of 93 of the 717 assessed athletes (13%) sustained re-injuries with graft ruptures, and in 91 of 652 patients (14%), contralateral ACL injuries were reported on final follow-up.
Conclusion
Pooled results suggest a high rate of return to sport following ACL reconstruction in children and adolescent athletes; however, this is associated with a relatively high rate of graft rupture and a similar rate of contralateral ACL injury. This study provides clinicians with evidence-based data on the ability of children and adolescent athletes to return to sport after ACL reconstruction, an important consideration for athletes of this population with ACL injuries.
Level of evidence
IV, systematic review of level IV studies.
Increasing evidence supports the finding that patients undergoing a total knee arthroplasty with high-volume physicians and hospitals achieve better outcomes. Unfortunately, the existing definitions ...for high-volume surgeons and hospitals are highly variable and entirely arbitrary. The aim of this study was to identify a set of meaningful hospital and surgeon total knee arthroplasty volume thresholds.
Using 289,976 patients undergoing primary total knee arthroplasty from an administrative database, we applied stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve to generate sets of volume thresholds most predictive of adverse outcomes. The outcomes considered for surgeon volume included 90-day complication and 2-year revision. For hospital volume, we considered 90-day complications and 90-day mortality.
SSLR analysis of the ROC curves for 90-day complication and 2-year revision rates by surgeon volume identified four volume categories: 0 to 12, 13 to 59, 60 to 145, and ≥146 total knee arthroplasties per year. Complication rates decreased significantly (p < 0.05) in progressively higher-volume categories. Revision rates followed a similar pattern, but did not decrease between surgeons performing 60 to 145 arthroplasties per year and those performing ≥146 arthroplasties per year. SSLR analysis of 90-day complication and 90-day mortality rates by hospital volume also identified four volume categories: 0 to 89, 90 to 235, 236 to 644, and ≥645 total knee arthroplasties per year. Complication rates decreased significantly (p < 0.05) in progressively higher-volume categories, but the rates did not decrease between hospitals performing 236 to 644 arthroplasties per year and those performing ≥645 arthroplasties per year. Mortality rates for hospitals with ≥645 total knee arthroplasties per year were significantly lower (p < 0.05) than those below the threshold.
Our study supports the use of SSLR analysis of ROC curves for risk-based volume stratification in total knee arthroplasty volume-outcomes research. SSLR analysis established meaningful volume definitions for low, medium, high, and very high-volume total knee arthroplasty surgeons and hospitals. This should help patients, surgeons, hospitals, and policymakers to make decisions with regard to the optimal delivery of total knee arthroplasty.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Background:
There have been no population-based studies to evaluate the rate of pediatric anterior cruciate ligament (ACL) reconstruction.
Purpose:
The primary aim of the current study was to ...determine the yearly rate of ACL reconstruction over the past 20 years in New York State. Secondary aims were to determine the age distribution for ACL reconstruction and determine whether patient demographic and socioeconomic factors were associated with ACL reconstruction.
Study Design:
Descriptive epidemiology study.
Methods:
The Statewide Planning and Research Cooperative System (SPARCS) database contains a census of all hospital admissions and ambulatory surgery in New York State. This database was used to identify pediatric ACL reconstructions between 1990 and 2009; ICD-9-CM (International Classification of Diseases, 9 Revision, Clinical Modification) and CPT-4 (Current Procedural Terminology, 4th Revision) codes were used to identify reconstructions. Patient sex, age, race, family income, education, and insurance status were assessed.
Results:
The rate of ACL reconstruction per 100,000 population aged 3 to 20 years has been increasing steadily over the past 20 years, from 17.6 (95% confidence interval CI, 16.4-18.9) in 1990 to 50.9 (95% CI, 48.8-53.0) in 2009. The peak age for ACL reconstruction in 2009 was 17 years, at a rate of 176.7 (95% CI, 160.9-192.5). In 2009, the youngest age at which ACL reconstruction was performed was 9 years. The rate of ACL reconstruction in male patients was about 15% higher than in females, and ACL reconstruction was 6-fold more common in patients with private health insurance compared with those enrolled in Medicaid.
Conclusion:
This study is the first to quantify the increasing rate of ACL reconstructions in the skeletally immature. Only ACL reconstructions were assessed, and it is possible that some ACL tears in children are not diagnosed or are treated nonoperatively. The rate of ACL tears in New York State is likely higher than the rate of reconstructions reported in this study.
Significance:
This study quantifies the increasing rate of ACL reconstruction in the skeletally immature and suggests that there may be some disparities in care based on insurance status.
Updating the assignment of levels of evidence Marx, Robert G; Wilson, Sean M; Swiontkowski, Marc F
Journal of bone and joint surgery. American volume,
01/2015, Letnik:
97, Številka:
1
Journal Article
Reporting the results of a randomized trial can be complex. In some cases, the primary outcome may not achieve statistical significance (usually defined as P ≤ .05) but the information may be ...clinically meaningful. “Spinning” the results of a study to show them to be more favorable than they are in reality is a form of reporting bias. The best way around potential reporting bias is for readers to read the methods section first to evaluate exactly what was done, followed by the results section to interpret the outcomes and analysis. Then, and only then, can readers decide whether the findings are relevant to them and their patients.
Background:
Hip arthroscopy has emerged as a successful option for the treatment of femoroacetabular impingement and related hip disorders, but the procedure is technically challenging.
Purpose:
To ...define the learning curve through which surgeons become proficient at hip arthroscopy.
Study Design:
Cohort study; level of evidence, 3.
Methods:
The authors identified hip arthroscopy procedures performed by surgeons through a New York State database (Statewide Planning and Research Cooperative System) and followed those cases for additional hip surgery (total hip arthroplasty, hip resurfacing, or ipsilateral hip arthroscopy) within 5 years of the original procedure. Career volume for each case was calculated as the number of hip arthroscopy procedures that the surgeon had performed. Volume strata were identified via the stratum-specific likelihood ratio method. A Cox proportional hazards model was used to measure the effect of surgeon career volume on risk of additional hip surgery, adjusting for the following patient characteristics: age, sex, race/ethnicity, insurance type, and concurrent diagnosis of hip osteoarthritis.
Results:
Among 8041 hip arthroscopies performed by 251 surgeons, 989 (12.3%) cases underwent additional hip surgery within 5 years. Four strata of surgeon career volume associated with distinct frequencies of reoperation were identified: cases in the lowest stratum (0-97) had the highest frequency of additional surgery (15.4%). Frequencies declined for cases in the medium (98-388), high (389-518), and highest (≥519) strata (13.8%, 10.1%, and 2.6%, respectively). There was an increased risk of subsequent surgery in each stratum when compared with the highest stratum (hazard ratio 95% CI: low volume, 3.22 2.29-4.54; medium, 3.40 2.41-4.82; high, 2.81 1.86-4.25; P < .0001 for all). Patients with a diagnosis of hip osteoarthritis had increased risk of subsequent hip arthroplasty or resurfacing (2.46 2.09-2.89, P < .0001) . Risk also increased with age: 30 to 39 vs ≤29 years (5.12 3.29-8.00, P < .0001), 40 to 49 vs ≤29 years (11.30 7.43-17.190, P < .0001), ≥50 vs ≤29 years (18.39 12.10-27.96, P < .0001). Increased age and osteoarthritis were not risk factors for revision hip arthroscopy.
Conclusion:
The learning curve for hip arthroscopy was unexpectedly demanding. Cases performed by surgeons with career volumes ≥519 had significantly lower risk of subsequent hip surgery than those performed by lower-volume surgeons.
Although the quality of knee arthroscopy is not determined with a stopwatch, in general, an operation should not take significantly longer than average for a routine and uncomplicated procedure. On ...the other hand, rushing through an operation is never acceptable. Hurrying to complete an operation to meet a given time standard is not only undesirable, but also unsafe for the patient.
Anterior cruciate ligament reconstruction is widely accepted as the treatment of choice for individuals with functional instability due to anterior cruciate deficiency. There remains little ...information on the epidemiology of anterior cruciate ligament reconstruction with regard to adverse outcomes such as hospital readmission and subsequent knee surgery. We sought to identify the frequency of anterior cruciate ligament reconstruction, the rates of subsequent operations and readmissions, and potential predictors of these outcomes.
The Statewide Planning and Research Cooperative System (SPARCS) database, a census of all hospital admissions and ambulatory surgery in New York State, was used to identify anterior cruciate ligament reconstructions performed between 1997 and 2006. Patients with concomitant pathological conditions of the knee were included. The patients were tracked for hospital readmission within ninety days after the surgery and for subsequent surgery on either knee within one year. The risks of these outcomes were modeled with use of age, sex, comorbidity, hospital and surgeon volume, and inpatient or outpatient surgery as potential risk factors.
We identified 70,547 anterior cruciate ligament reconstructions, with an increase from 6178 in 1997 to 7507 in 2006. Readmission within ninety days after the surgery was infrequent (a 2.3% rate), but subsequent surgery on either knee within one year was much more common (a 6.5% rate). Patients were at increased risk for readmission within ninety days if they were over forty years of age, sicker (e.g., had a preexisting comorbidity), male, and operated on by a lower-volume surgeon. Predictors of subsequent knee surgery included being female, having concomitant knee surgery, and being operated on by a lower-volume surgeon. Predictors of a subsequent anterior cruciate ligament reconstruction included an age of less than forty years, concomitant meniscectomy or other knee surgery, and surgery in a lower-volume hospital.
The rate of anterior cruciate ligament reconstruction has increased in frequency. Also, while anterior cruciate ligament reconstruction appears to be a safe procedure, the risk of a subsequent operation on either knee is increased among younger patients and those treated by a lower-volume surgeon or at a lower-volume hospital.
Background:
Knee laxity in the setting of anterior cruciate ligament (ACL) injury is often assessed through physical examination using the Lachman, pivot shift, and anterior drawer tests. The degree ...of laxity noted on these examinations may influence treatment decisions and prognosis.
Hypothesis:
Increased preoperative knee laxity is associated with increased risk of revision ACL reconstruction, increased risk of contralateral ACL reconstruction, and poorer patient-reported outcomes at 6 years postoperatively.
Study Design:
Cohort study; Level of evidence, 2.
Methods:
2333 patients who underwent primary isolated ACL reconstruction without additional ligament injury were identified. Patients reported by the operating surgeons to have an International Knee Documentation Committee (IKDC) grade D Lachman, anterior drawer, or pivot shift examination were classified as having a high-grade laxity. Multiple logistic regression models were used to evaluate whether having high-grade preoperative laxity was predictive of increased odds of undergoing subsequent revision or contralateral ACL reconstruction within 6 years of the index procedure, controlling for patient age, sex, body mass index, Marx activity level, sport, graft type, medial meniscal treatment, and lateral meniscal treatment. Multiple linear regression modeling was used to evaluate whether having high-grade preoperative laxity was predictive of poorer IKDC or Knee injury and Osteoarthritis Outcome Score Knee-Related Quality of Life (KOOS-QOL) scores at 6 years postoperatively, after controlling for baseline score, patient age, ethnicity, sex, body mass index, marital status, smoking status, sport participation, competition level, Marx activity rating score, graft type, and articular cartilage and meniscal status.
Results:
In total, 743 of 2325 patients (32.0%) were noted to have high-grade laxity on at least 1 physical examination test. High-grade Lachman was noted in 334 patients (14.4%), high-grade pivot shift was noted in 617 patients (26.5%), and high-grade anterior drawer was noted in 233 patients (10.0%). Six-year revision and contralateral ACL reconstruction data were available for 2129 patients (91.6%). High-grade prereconstruction Lachman was associated with significantly increased odds of ACL graft revision (odds ratio OR, 1.76; 95% CI, 1.10-2.80, P = .02) and contralateral ACL reconstruction (OR, 1.68; 95% CI, 1.09-2.69; P = .019). High-grade prereconstruction pivot shift was associated with significantly increased odds of ACL graft revision (OR, 1.75; 95% CI, 1.19-2.54, P = .002) but not with significantly increased odds of contralateral ACL reconstruction (OR, 1.30; 95% CI, 0.89-1.87; P = .16). High-grade prereconstruction laxity was associated with statistically significantly lower 6-year IKDC (β = −2.26, P = .003), KOOS-QOL (β = −2.67, P = .015), and Marx activity scores (β = −0.54, P = .020), but these differences did not approach clinically relevant differences in patient-reported outcomes.
Conclusion:
High-grade preoperative knee laxity is predictive of increased odds of revision ACL reconstruction and contralateral ACL reconstruction 6 years after ACL reconstruction. Poorer patient-reported outcome scores in the high-grade laxity group were also noted, but the difference did not reach a level of clinical relevance.
PDF