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Background: Patients with persistent glenohumeral osteoarthritis symptoms despite nonoperative management may pursue anatomic total shoulder arthroplasty (TSA). TSA revision rates are higher in patients with preoperative eccentric (asymmetric posterior erosion) compared with concentric (symmetric) glenoid deformity. If posterior rotator cuff deficiency demonstrated preoperatively in patients with eccentric deformity persists after TSA, it may manifest as relative weakness in external compared with internal rotation secondary to deficient activity of the shoulder external rotator muscles. Persistent posterior rotator cuff deficiency is hypothesized to contribute to TSA failures. However, it remains unknown whether rotational strength is impaired after TSA in patients with eccentric deformity. Our goal was to determine if patients with eccentric deformity exhibit relative external rotation weakness that may be explained by posterior rotator cuff deficiency after TSA.

Methods: Patients who were >1 year after TSA for primary glenohumeral osteoarthritis and had had preoperative eccentric or concentric deformity were prospectively recruited. Torque was measured and electromyography was performed during maximal isometric contractions in 26 three-dimensional direction combinations. Relative strength in opposing directions (strength balance) and muscle activity of 6 shoulder rotators were compared between groups.

Results: The internal (+) and external (-) rotation component of strength balance did not differ in patients with eccentric (mean internal-external rotation component of strength balance: -7.6% ± 7.4%) compared with concentric deformity (-10.3% ± 6.8%) (mean difference: 2.7% [95% confidence interval (CI), -1.3% to 6.7%]; p = 0.59), suggesting no relative external rotation weakness. Infraspinatus activity was reduced in patients with eccentric (43.9% ± 10.4% of maximum voluntary contraction [MVC]) compared with concentric (51.3% ± 10.4% of MVC) deformity (mean difference: -7.4% [95% CI, -13.4% to -1.4%] of MVC; p = 0.04).

Conclusions: A relative external rotation strength deficit following TSA was not found, despite evidence of reduced infraspinatus activity, in the eccentric-deformity group. Reduced infraspinatus activity suggests that posterior rotator cuff deficiencies may persist following TSA in patients with eccentric deformities. Longitudinal study is necessary to evaluate muscle imbalance as a contributor to higher TSA failure rates.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: The functional benefits of total wrist arthroplasty (TWA) over total wrist fusion (TWF) are unknown. The purpose of this prospective cohort study was to compare TWA and TWF with respect to functional outcomes and activity limitations at up to 2 years postoperatively.

Methods: Between 2015 and 2020, we enrolled all adult patients undergoing TWA or TWF for the management of symptomatic end-stage wrist arthritis at 1 hand surgery department. The primary outcome was the Patient-Rated Wrist Evaluation (PRWE). The secondary outcomes were the visual analog scale (VAS) for pain at rest, on motion, and on loading; grip strength; Disabilities of the Arm, Shoulder and Hand (DASH); and range of motion. Patients completed questionnaires and were examined by the same physiotherapist at baseline and at 3, 6, 12, and 24 months postoperatively. Mixed-model analyses adjusting for age, diagnosis, the preoperative value of the dependent variable, and time since surgery were performed to compare differences in PRWE scores, VAS pain scores, and grip strength between TWA and TWF.

Results: Of the 51 patients who had been included at baseline, 47 (18 in the TWA group and 29 in the TWF group) responded to questionnaires and underwent examinations at up to 2 years postoperatively. At baseline, the 2 groups did not differ in terms of age, sex, diagnosis (inflammatory or noninflammatory arthritis), PRWE score, VAS pain score, grip strength, DASH score, or range of motion. No differences between the groups were found for the PRWE (β, -0.1; 95% confidence interval [CI], -14 to 13; p = 0.99), VAS pain at rest (β, -3.3; 95% CI, -15 to 9; p = 0.58), VAS pain on loading (β, -5.3; 95% CI, -22 to 11; p = 0.52), or grip strength (β, -0.02; 95% CI, -0.18 to 0.14; p = 0.80) on the adjusted mixed-model analyses.

Conclusions: Among patients with symptomatic end-stage wrist arthritis, those who underwent TWA did not demonstrate short-term outcomes, including patient-reported disability, pain, and grip strength, superior to those of patients who underwent TWF. These findings call into question the widespread use of TWA.

Level of evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: Fracture-related infection is one of the most challenging complications in orthopaedic trauma surgery. However, the effect of infection on functional and pain-related outcomes has not been well established. The aims of this study were to evaluate functional recovery for patients with fracture and a deep surgical site infection compared with patients with fracture without infection and to evaluate whether pain severity, social support, and preinjury mental health have a moderating effect on the magnitude and direction of the relationship between deep surgical site infection and functional recovery.

Methods: This is a secondary retrospective cohort study using prospectively collected data from the VANCO trial (Local Antibiotic Therapy to Reduce Infection After Operative Treatment of Fractures at High Risk of Infection) and the OXYGEN (Supplemental Perioperative Oxygen to Reduce Surgical Site Infection After High Energy Fracture Surgery) trial. In this study, 2,116 patients with tibial plateau, pilon, or calcaneal fractures at high risk for infection were included. Patients were divided into cohorts of patients who experienced a deep surgical site infection and those who did not. The primary outcome measure was the functional outcome using the Veterans RAND 12-Item Health Survey (VR-12).

Results: After controlling for covariates, deep surgical site infection was independently associated with functional outcome, with a 3.3-point reduction in the VR-12 Physical Component Score, and pain severity was independently associated with functional outcome, with a 2.5-point reduction in the VR-12 Physical Component Score. Furthermore, the Brief Pain Inventory pain severity demonstrated an important moderating effect on the relationship between infection and functional outcome. In patients with lower pain scores, infection had a large negative impact on functional outcome, whereas, in patients with higher pain scores, infection had no significant impact on functional outcome. Furthermore, the functional outcome in the entire cohort remains at only 61% of baseline.

Conclusions: This study documents the negative impact of postoperative infection on functional recovery after injury, as well as the novel finding of pain severity as an important moderating factor. This study emphasizes not only the importance of developing effective interventions designed to reduce postoperative infection, but also the role that factors that moderate pain severity plays in limiting recovery of physical function.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective: We aimed to elucidate associations between geographic location, size, and ranking of medical schools that orthopaedic surgery residents graduate from and the residencies that they match both pre-COVID-19 and post-COVID-19 pandemic by examining the 2017 to 2022 orthopaedic surgery residency cohorts.

Methods: Demographics were extracted using Doximity Residency Navigator platform, the 2021 US News and World Report, and program websites. Medical schools were classified as large if they had >613 medical students. Postgraduate year 1 (PGY-1) (2021 match) and PGY-2 (2022 match) residents were classified as the COVID-19 cohort. Location was categorized as Northeast, Midwest, South, and West. Chi-square tests, Cohen's H value, and descriptive statistics were used for analysis with statistical significance set at p <0.05.

Results: Four thousand two hundred forty-three residents from 160 accredited US orthopaedic residency programs (78.4%) were included. Northeastern applicants were most likely to match in the same region (p <0.01), and southern applicants were most likely to match at their home program (p <0.001). Applicants affected by the COVID-19 pandemic did not differ from their predecessors with regards to matching to the same region (p = 0.637) or home program (p = 0.489). Applicants from public medical schools were more likely to match in the same region and at their home program (p <0.001), whereas those from private medical schools were more likely to match at top-ranked residencies (p <0.001). Students from both top 25- and top 50-ranked medical schools were more likely to match at their home program (p <0.01) and attend top 20-ranked residency programs (p <0.0001).

Conclusion: These results demonstrate significant associations between matched residencies and attended medical schools' geographic location, school type, and ranking. During the pandemic, geographic trends were overall unchanged, whereas residents from large or lower-ranked schools were more likely to match at home programs, and those from private or top-ranked schools were less likely to attend top residencies.

Background: There is growing evidence of increased venous thromboembolism (VTE) incidence in children with trauma or infection. The purpose of this study was to conduct a systematic review of existing literature related to VTE in the pediatric orthopaedic population, to estimate the overall incidence of VTE and identify risk factors associated with this condition.

Methods: A systematic review of the available literature was performed to identify articles that described VTE in pediatric orthopaedic surgery or admission. Literature queries were performed to identify articles published from 1980 to 2021 that included patients ≤21 years of age. A stepwise search strategy of 5 electronic databases yielded 1,426 articles, which were filtered by 2 reviewers to identify 30 articles for full-text review. The primary aim was to determine the rate of VTE, and the secondary aim was to identify risk factors for VTE. The pooled incidence of VTE was estimated and reported in cases per 10,000. Studies were stratified by study size, by trauma versus elective surgery, and by orthopaedic subspecialty.

Results: The 30 articles reported 3,113 VTE events in 2,467,764 pediatric patients (including those with non-orthopaedic conditions), for a pooled VTE incidence of 20 events (95% confidence interval [CI] = 10.8 to 37.2) per 10,000. Four of the studies were excluded for incomplete data or high heterogeneity. The remaining 26 studies had 850,268 orthopaedic patients with 1,108 cases of VTE, for a pooled VTE incidence of 16.6 events (95% CI = 9.1 to 30.5) per 10,000. Studies with <10,000 patients and those involving a diagnosis of trauma had the highest VTE incidence when stratification was performed. The most frequently analyzed risk factors in 15 available studies included age, sex, obesity/body mass index, type of surgery, and use of a central venous catheter.

Conclusions: This systematic review indicated that the risk of VTE associated with pediatric orthopaedic surgery or admission remains low, at <17 events per 10,000 cases. However, orthopaedic surgeons should be aware of the most common risk factors associated with pediatric orthopaedic VTE and should pay special attention to traumatic etiologies, as these yielded the highest incidence.

Levels of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: The study aims to develop a data-driven methodology to assess bone drilling in preparation for future clinical trials in residency training. The existing assessment methods are either subjective or do not consider the interdependence among individual skill factors, such as time and accuracy. This study uses quantitative data and radar plots to visualize the balance of the selected skill factors.

Methods: In the experiment, straight vertical drilling was assessed across 3 skill levels: expert surgeons (N = 10), intermediate residents (postgraduate year-2-5, N = 5), and novice residents (postgraduate year-1, N = 10). Motion and force were measured for each drilling trial, and data from multiple trials were then converted into 5 performance indicators, including overshoot, drilling time, overshoot consistency, time consistency, and force fluctuation. Each indicator was then scored between 0 and 10, with 10 being the best, and plotted into a radar plot.

Results: Statistical difference (p < 0.05) was confirmed among 3 skill levels in force, time, and overshoot data. The radar plots revealed that the novice group exhibited the most distorted pentagons compared with the well-formed pentagons observed in the case of expert participants. The intermediate group showed slight distortion that was between the expert and novice groups.

Conclusion/clinical relevance: This research shows the utility of radar plots in drilling assessment in a comprehensive manner and lays the groundwork for a data-driven training scheme to prepare novice residents for clinical practice.

Background: Tourniquet application in total knee arthroplasty (TKA) has many benefits and may have a role in the incidence of perioperative complications. Our aims were to examine the safety of applying a tourniquet for a limited amount of time during primary unilateral TKA (specifically, during cementation and final component fixation only) and to compare perioperative complications between the limited-application group and the full-application group.

Methods: We conducted a randomized controlled study of 62 patients undergoing primary unilateral TKA. Patients were randomly allocated to either the limited or full tourniquet application. The follow-up period was 6 months. We evaluated intraoperative, postoperative, total, and hidden blood loss as the primary outcome measures and clearance of the surgical field, operative duration, and perioperative complications as the secondary outcome measures.

Results: We found a significant difference in surgical field clearance between the groups. There was no significant difference in total, hidden, or postoperative blood loss between the groups. Mean intraoperative blood loss was significantly lower in the full-application group than in the limited-application group (171.742 ± 19.710 versus 226.258 ± 50.290 mL; p = 0.001). Perioperative complications, including allogeneic blood transfusion rates, did not significantly differ between the groups.

Conclusions: Limited tourniquet application is safe to use in primary unilateral TKA and does not increase the incidence of perioperative complications or total blood loss when compared with a standard, full-time tourniquet application.

Level of evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: It is largely unknown if and when patients return to daily activities after undergoing total hip arthroplasty (THA) and which factors might influence this return. This study aimed to assess the percentages of patients who had been able to return to daily activities, work, and sports at 3 months after THA. Furthermore, the time to return and factors influencing the return (patient characteristics, surgical characteristics, and preoperative patient-reported outcomes) were assessed.

Methods: A retrospective cohort study of patients who underwent THA was performed with use of prospectively collected data. At 3 months postoperatively, patients completed a questionnaire regarding their return to 16 different activities across the categories of daily activities, work, and sports. The percentage of patients who returned to an activity, the time to return, and factors influencing the return were analyzed with use of logistic regression models utilizing backward selection.

Results: A total of 2,006 patients were studied. Most of the studied activities had been returned to by the majority of patients at 3 months after THA, with the percentage of patients who returned to an activity ranging from 28.8% to 97.9%. The mean or median time to return to an activity ranged from 1 to 56 days after THA. For 13 out of 16 activities, 1 or more of the studied factors influenced the return to the activity. R² values ranged from 0.057 to 0.273.

Conclusions: At 3 months after THA, 8 out of 10 patients had returned to daily activities, 7 out of 10 had returned to work, and 5 out of 10 had returned to sports. Factors that clearly influenced the return to daily activities, work, and sports could not be established. These findings might be useful in setting realistic expectations when counselling patients on their return to daily activities, work, and sports after THA.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Graft choice for anterior cruciate ligament reconstruction (ACLR) has been evolving. The peroneus longus tendon (PLT) has been seen as a suitable choice for ACLR, providing comparable results to those of hamstring tendon (HT) autograft, but its clinical relevance in terms of return to sports, to our knowledge, has not been studied.

Methods: Two hundred and thirty-two patients who sustained an isolated ACL injury were enrolled and underwent ACLR using doubled PLT autograft or quadrupled HT autograft; 158 were followed for 24 months. Functional scores (International Knee Documentation Committee [IKDC] and Tegner-Lysholm scores) were assessed preoperatively and at 3,6, 12, and 24 months postoperatively. Graft diameter and graft harvesting time were measured intraoperatively. Donor-site morbidity was evaluated using subjective evaluation. Time to return to sports in both groups was compared.

Results: The mean diameter of PLT autograft was significantly larger than that of HT autograft, and the mean graft-harvesting time was less (p < 0.001). Patients in the PLT group returned to sports a mean of 34 days earlier than those in the HT group (p < 0.001) and had a lower rate of donor-site morbidity and, at 6 months, better patient-reported outcomes at the knee (p < 0.001). There were no significant differences between the groups in the rate of graft rupture or in IKDC and Tegner-Lysholm scores at the 24-month follow-up.

Conclusions: PLT is a suitable autograft for ACLR in terms of graft diameter and graft-harvesting time and may offer athletes an earlier return to sports related to better outcomes at 6 months of follow-up. HT autograft was associated with increased thigh weakness. Both grafts, however, performed similarly at 24 months postoperatively.

Level of evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.