Thomas P. Branch

The study aimed to establish a real-world benchmark of recovery following rotator cuff repair (RCR) using healthcare claims data. Secondary objectives included determining the effect of comorbidities and complications such as joint contracture, additional procedures, and rehospitalizations on the recovery timeline and costs. Healthcare claims data from the IBM MarketScan Commercial Claims and Encounters Database (2015-2018) were reviewed to determine costs and recovery time after RCR. Costs and recovery duration (index surgery to last therapy claim) were calculated. Subgroup analyses assessed the effects of comorbidities (diabetes, obesity, peripheral vascular disease, cardiovascular disease) and postoperative events (revision, motion restoring surgery (MRS), complication-related surgery, and nonoperative hospitalization) on outcomes. Perioperative complications including joint fibrosis/contracture, infection, and pulmonary embolus were also reported. Descriptive statistics including medians with interquartile ranges (IQR) were reported. In the 14,947 patients included in analysis, median index surgery cost was $11,454 (IQR: $8,169-$17,204). Median recovery was 153 days (IQR: 79-683). Development of postoperative shoulder contracture or adhesive capsulitis added a median of 162 recovery days and nearly doubled costs. Patients requiring surgery for a complication had 3.5-fold longer recoveries and fivefold higher costs than those without complications. MRS increased recovery time and costs nearly threefold, and patients undergoing MRS were seven times more likely to require arthroplasty. Comorbidities extended recovery by 30-90 days, modestly increased costs, and were associated with a 2-3 times higher frequency of pulmonary embolism. Claims data may be affected by coding inconsistencies, lack of clinical detail, and inability to capture medication costs or outcomes beyond the last therapy claim. This study defined a benchmark for recovery after RCR and found that complications including contracture and motion restoring surgery substantially increased recovery time and costs. These benchmarks can guide earlier identification of patients at risk for delayed recovery and help in evaluating strategies to reduce economic burden and improve outcomes.

The aim of this paper was to determine a claims-based timeline of unilateral elbow fracture recovery including the effect of comorbidities and post-treatment complications on recovery. This study utilized data from the IBM MarketScan database (2015-2018) to assess costs and recovery timelines after unilateral elbow fracture treatment. All costs are reported in U.S. dollars and reflect prices during the 2015-2018 period. Costs examined included: i) index surgery/treatment, ii) complication surgery, iii) revision or salvage surgeries, iv) non-operative hospitalization, v) motion restoring surgery and vi) additional elbow-related outpatient surgery. Costs of related physician visits, physical/occupational therapy and diagnostic radiology were also incorporated. The impact of comorbidities-diabetes, obesity, peripheral vascular disease, and cardiovascular disease-was evaluated. Additionally, data on re-hospitalizations, with or without further surgery, were analyzed to understand complications after the initial treatment. Perioperative complications including joint fibrosis/contracture, infection, and pulmonary embolus were also reported. Index surgery/treatment median cost and length of post-treatment recovery (from index surgery/treatment to last physical/occupational therapy claim) was $4,494 ($872-$10,444) and 102.5 days (36-480 days), respectively. A total of 59% of patients completed their post-treatment period in six months with 41% of patients taking longer. Patients that required a complication surgery had median recovery times and costs that increased three- and seven-fold, respectively, in comparison to those without complication surgeries. Comorbidities added 66-113 days to recovery. Peripheral and cardio-vascular disease coincided with 1.7 to 3 times higher post-treatment costs. Comorbidities and complications following elbow fracture treatment lead to substantial increases in both costs and recovery durations. Understanding the typical recovery timeline after elbow fracture treatment, as well as the variations in outlier patients, can assist in optimizing recovery management and guiding appropriate interventions.

Background/Objectives: Types I, V, and XI collagen gene variants have been reported to associate with measurements of knee joint laxity and/or absolute knee ligament length changes. Type XII collagen and tenascin C are also ligament structural proteins whose expression is regulated by mechanical loading. This study investigated whether COL12A1 and TNC variants are associated with knee laxity and/or ligament length changes. Methods: Genu recurvatum, anterior–posterior tibial translation, external–internal tibial rotation, and ligament length changes were measured in 128 healthy participants. They were genotyped for COL12A1 (rs970547) and TNC (rs1061494, rs2104772, rs1138545). Results: Both the COL12A1 AA and TNC rs1061494 TT genotypes were associated with decreased external (p = 0.007, p = 0.010) and internal (p = 0.025, p = 0.002) rotation, as well as slack (p = 0.033, p = 0.014), in the dominant leg. Both genotypes, together with sex, weight, and/or COL1A1 genotypes, explained 26% and 32% of the variance in external and internal rotation, respectively. The TNC genotype, sex, and BMI explained 23% of the variance in slack. The COL12A1 AA and the TNC rs1061494 TT genotypes were associated with smaller changes in the MCL (aMCL: COL12A1 p = 0.009, TNC p = 0.045; iMCL: COL12A1 p = 0.004, TNC p = 0.043; pMCL: COL12A1 p = 0.003, TNC p = 0.067; aDMCL: COL12A1 p = 0.007, TNC p = 0.020; pDMCL: COL12A1 p = 0.007, TNC p = 0.023) and/or LCL (COL12A1 p = 0.652, TNC p = 0.049) lengths within the dominant knee. The TNC rs1061494 CC genotype was associated with larger changes in the non-dominant anterior (p = 0.021) and posterior (p < 0.001) ACL bundle lengths. Conclusions: These findings suggest that COL12A1 and TNC variants are associated with internal–external tibial rotation and knee ligament length changes in healthy individuals.

Joint laxity is a multifactorial phenotype with a heritable component. Mutations or common polymorphisms within the α1(V) (COL5A1), α1(XI) (COL11A1) and α2(XI) (COL11A2) collagen genes have been reported or proposed to associate with joint hypermobility, range of motion and/or genu recurvatum. The aim of this study was to investigate whether polymorphisms within these collagen-encoding genes are associated with measurements of knee joint laxity and computed ligament length changes within the non-dominant leg. One hundred and six healthy participants were assessed for genu recurvatum (knee hyperextension), anterior-posterior tibial translation, external-internal tibial rotation and ligament length changes during knee rotation of their non-dominant leg. Participants were genotyped for COL5A1 rs12722 (T/C), COL11A1 rs3753841 (C/T), COL11A1 rs1676486 (T/C) and COL11A2 rs1799907 (A/T). The genotype-genotype combination of any two or more of the four COL5A1 rs12722 CC, COL11A1 rs3753841 CC, COL11A1 rs1676486 TT and COL11A2 rs1799907 AA genotypes was associated with decreased active and passive knee hyperextension. These genotype-genotype combinations, including sex (male), increased age and decreased body mass collectively, also contributed to decreased passive knee hyperextension. These findings suggest that COL5A1, COL11A1 and COL11A2 gene-gene interactions are associated with knee hyperextension measurements of the non-dominant leg of healthy individuals.

The presence of a positive pivot shift after surgical repair of the ACL is considered an important indicator of a failed reconstruction. The ability to predict the result of a pivot shift test after an ACL reconstruction using variables that can be measured prior to surgery could provide an indication of which patients may be at-risk of a poor surgical outcome.The purpose of this study was to determine whether structural characteristics of the femur and tibia, measured using plain radiographs, were associated with the result of the pivot shift test in unilateral ACL reconstructed patients. Sixteen patients who had undergone unilateral ACL reconstruction were divided into two groups based on the results of manual pivot shift testing: 1) Pivot group; and 2) No pivot group. All patients had standing true lateral radiographs of both knees. Structural measurements of the tibia and femur were made on both knees. In addition, two new variables were created to describe the tibiofemoral mismatch: 1) Femur Tibia Size Ratio (FTSR); and 2) Tibia to Posterior Femoral Condyle Ratio (TPFCR). These measures were compared within groups and between groups. None of the individual structural characteristics were significantly different when compared between groups. No individual structural characteristics had a significant association with the presence of a positive pivot shift. When a between-group analysis was performed, both the FTSR (p < 0.03) and the TPFCR (p < 0.01) were significantly different between the Pivot group and the No Pivot group. A larger FTSR ratio, or a larger femur relative to the tibia, was associated with a positive pivot shift. A smaller TPFCR ratio, or a smaller tibial depth relative to the depth of the lateral posterior femoral condyle, was associated with a positive pivot shift. Structural characteristics in the lateral femoral condyle and lateral tibial plateau were found to be associated with the presence of a positive pivot shift. These characteristics could separate between patients in the Pivot group and the No Pivot group. Two indices, the FTSR and the TPFCR, provided better predictive value than individual characteristics in identifying patients with a knee that was structurally “at-risk” for developing a positive pivot shift.

The purpose of this study was to evaluate the separate contribution of the two definitions of the anterolateral ligament (ALL), the mid-third lateral capsular ligament (MTLCL) and deep capsule-osseous layer of the iliotibial tract (dcITT) in addition to the superficial iliotibial tract (sITT) to the control of tibial motion with respect to the femur during the application of force/torque seen during the three tests of the standard clinical knee examination (AP Lachman test, tibial axial rotation test and varus–valgus stress test).

Objective: The purpose of this retrospective cohort study was to compare range of motion, subjective outcomes, and the prevalence of reoperation in groups of frozen shoulder patients with either low or moderate/high irritability treated with the same total end range time-maximizing protocol. Design: A total of 36 patients were treated with the total end range time-maximizing protocol (12 patients with low irritability and 24 patients with moderate/high irritability). American Shoulder and Elbow Society Standardized Shoulder Assessment Form (ASES) scores and external rotation and abduction were recorded before and after the rehabilitation protocol and were compared between the two groups. Results: For both groups, external rotation and abduction of the involved shoulder significantly increased from pretreatment to posttreatment, and the posttreatment external rotation and abduction of the involved shoulder did not differ from those of the uninvolved shoulder. There were no differences between the groups in either external rotation (P = 0.71) or abduction (P = 0.46). ASES scores were significantly lower and pain scores were significantly higher for the moderate/high irritability group both before and after treatment than for the low irritability group; however, the moderate/high irritability group demonstrated significantly greater gains in both ASES and pain scores. One patient in the low irritability group underwent a lysis of adhesions. Conclusions: We conclude that a total end range time-maximizing rehabilitation protocol is a safe, effective treatment option for patients with frozen shoulder.

Purpose: To compare the subjective clinical results as well as manual anterior and rotational stability in patients treated with either single‐ (SB) or double‐bundle (DB) anterior cruciate ligament (ACL) reconstructions.Methods: Sixty‐four patients who had undergone SB or DB hamstring ACL reconstruction with hamstrings were included in a retrospective matched pair analysis. At follow‐up IKDC subjective, CKS, KOOS, CKS and a visual analogue satisfaction scale was assessed. A blinded surgeon examined the joint laxity and completed the objective IKDC. The KT‐1000 was used to bilaterally test anterior tibial translation. Patients with confounding variables, which statistically influenced the clinical outcome (passive flexion and extension deficits, persistent quadriceps deficit, tibiofemoral osteoarthritis and non‐repairable medial meniscus injury), were identified and excluded from the statistical analysis (n = 10).Results: For all subjective scores, DB patients reported increased scores compared with SB patients. While consistently higher scores were demonstrated, statistical significance was only achieved for the IKDC subjective (P = 0.04) and VAS satisfaction (P = 0.02). Graded stability results of the Lachman, anterior drawer and pivot‐shift tests were significantly higher in the DB group and KT‐1000 side‐to‐side difference was significantly better for DB (P = 0.01).Conclusion: DB ACL reconstruction appeared to more consistently result in significantly higher subjective outcome scores and manual tests of joint stability than SB ACL reconstruction. Besides the surgical technique, normal extension and quadriceps strength after surgery were identified to be an essential component in order to provide the patient with a successful outcome.Level of evidence: II.