Iturregui, Jose M.

Introduction Krackow Type II valgus deformity is defined by attenuation of the medial collateral ligament (MCL). However, little quantitative information exists about associated intra-operative MCL laxity. Furthermore, a corollary may exist in varus deformity with associated lateral ligament laxity but is poorly described. Robotic-assisted total knee arthroplasty (raTKA) includes quantitative assessment of intraoperative ligament function. This study evaluated whether increased preoperative medial or lateral radiographic joint space width (JSW) in valgus or varus knees, was associated with increased intraoperative soft tissue laxity of the respective compartment. Methodology Intraoperative data from 348 consecutive raTKAs with 270 varus knees (hip-knee-ankle angle [HKA]<-2°), and 78 valgus knees, (HKA>2°) were retrospectively reviewed. For varus knees, lateral JSW was measured on preoperative, standing anteroposterior radiographs to determine lateral widening (threshold 8.0mm). For valgus knees, medial JSW was evaluated to determine medial widening (threshold 7.0mm). Intraoperative medial and lateral gaps at 0° and 90° had been recorded during manual stress testing. Linear regression was performed to determine associations between intra-operative gaps, radiographic JSW, and HKA. Results 51 varus knees demonstrated lateral widening and 15 valgus knees had medial widening. In varus knees, lateral JSW was positively associated with the lateral extension (β=0.76, P <0.001) and flexion (β=0.74, P <0.001) gaps. Similarly, for valgus knees, medial JSW was positively associated with the medial extension (β=0.75, P <0.001) and flexion (β=0.77, P <0.001) gaps. Conclusion Increased preoperative radiographic JSW of the medial and lateral compartment in valgus and varus knees, predicted increased intraoperative gaps of that compartment, consistent with ligament attenuation.

Background: Tendinopathies are common in middle-aged women. While estrogen regulates tendon remodeling, the influence of systemic hormone replacement therapy (HRT) on the risk of tendon degeneration remains unclear. Hypothesis/Purpose: The purpose of this study was to investigate the association between systemic HRT use and tendon injuries/repair in perimenopausal women. It was hypothesized that systemic HRT would be associated with an increased incidence of tendon injuries and repair. Study Design: Cohort study; Level of evidence, 4. Methods: Using the TriNetX Research Network, we identified female patients aged ≥45 years diagnosed with major tendon abnormalities, including rotator cuff tears, bicipital tendinitis, lateral or medial epicondylitis, Achilles tendinopathy, patellar tendinitis, or quadriceps strain, from January 2004 to July 2025. HRT exposure was defined as systemic estrogen and/or progestin use within 1 year before a diagnosis. Patients with contraindications to HRT were excluded. After 1:1 propensity score matching, 2 groups of 63,836 patients each were generated. Primary outcomes included diagnosis rates of specific tendon conditions; secondary outcomes were lifetime rates of corresponding tendon repair procedures. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. The independent t test and chi-square test were used for analysis. Results: HRT users had significantly higher rates of several tendon abnormalities compared to matched controls, including rotator cuff tears (39.2% vs 37.9%, respectively; P < .001), bicipital tendinitis (13.3% vs 11.0%, respectively; P < .001), lateral epicondylitis (27.8% vs 22.7%, respectively; P < .001), and medial epicondylitis (6.8% vs 5.3%, respectively; P < .001). Achilles tendinopathy had similar rates between the 2 groups (14.6% vs 14.5%, respectively; P = .387). Surgical repair was more common in the HRT group, including biceps tendon repair/tenodesis (3.9% vs 3.3%, respectively; OR, 1.16 [95% CI, 1.10-1.23]; P < .001), rotator cuff repair (6.6% vs 6.2%, respectively; OR, 1.06 [95% CI, 1.01-1.11]; P = .013), and Achilles tendon repair (0.7% vs 0.6%, respectively; OR, 1.23 [95% CI, 1.06-1.41]; P = .005). Conclusion: Our study showed that systemic HRT use in women aged ≥45 years was associated with an increased risk of tendon injuries and a greater likelihood of surgical repair, although the absolute risk differences were modest. These findings underscore the need for awareness of the possible musculoskeletal effects of hormone therapy and highlight an underexplored area in women's orthopaedic health.

Background: The aim of this study was to evaluate the prevalence and perceived efficacy of cannabidiol (CBD) products in patients presenting to an orthopedic hand and upper extremity clinic. Materials and Methods: New patients seen for an initial surgical consultation between July and December 2022 were surveyed regarding CBD use, pain, and function. Pain was measured with the Numeric Pain Rating Scale (NPRS, 0–10) and function with the Single Assessment Numeric Evaluation (SANE, 0–100). Demographic and clinical factors were collected via chart review. Results: A total of 918 patients completed the survey (53% female; mean age 63 years, range 18–97). Joints involved included elbows (106), wrists (335), and hands/fingers (667). Common diagnoses included arthritis (199), tendinopathy (273), and nerve-related conditions (160). Overall, 15% (135/918) reported prior CBD use, and 39% (53/135) perceived pain relief. CBD users were more likely to be female (65% vs 51%; P =0.003), to present with wrist pathology (44% vs 35%; P =0.038), and to have arthritis (36% vs 19%; P <0.001). Compared to non-users, CBD users reported higher pain scores (mean NPRS 6.2 vs 5.1; P <0.001) and lower contralateral function (mean SANE 77.3 vs 87.4; P <0.001). Conclusions In this cohort, CBD use was uncommon, and only a minority of users reported subjective benefit. CBD users tended to report higher pain and worse function, particularly in the setting of wrist arthritis. CBD products did not appear to provide measurable objective improvement in pain or function. Further studies are needed to clarify optimal dosing, administration, and potential role in upper extremity care.

Background: The purpose of this study was to investigate the association between cannabis use and postoperative complications following ankle and hindfoot arthrodesis. Methods: A retrospective cohort study using a large national insurance database from 2010 to 2022 was conducted. All patients who underwent ankle or hindfoot arthrodesis with at least 2 years’ follow-up were included. Patients were divided into 4 groups: cannabis-only users, tobacco-only users, cannabis and tobacco users, and nonuser controls. Groups were matched 1:4 with nonuser controls based on demographic variables and comorbidities. Also, both cannabis and tobacco users were matched 1:4 with tobacco-only users based on demographics and comorbidities. Medical complications within 90 days of surgery and surgery-specific complications within 2 years were compared between groups with multivariable logistic regressions. Results: Compared with nonuser controls, cannabis users only were not at increased risk of 90-day medical complications or 2-year surgical complications. Tobacco use alone was associated with increased risk of postoperative admission (OR 1.32, 95% CI 1.21-1.43) and emergency department (ED) utilization (OR 1.57, 95% CI 1.48-1.66) within 90 days as well as infection (OR 1.24, 95% CI 1.18-1.30), hardware removal (OR 1.12, 95% CI 1.07-1.18), nonunion (OR 1.33, 95% CI 1.27-1.40), and wound dehiscence (OR 1.38, 95% CI 1.27-1.49) within 2 years of surgery compared with nonuser controls. Compared with tobacco-only use, combined cannabis and tobacco use was associated with increased risk of ED visits within 90 days (OR 1.45, 95% CI 1.30-1.62) and nonunion within 2 years of surgery (OR 1.19, 95% CI 1.05-1.35). Conclusion: These findings suggest that although cannabis use alone was not associated with a higher risk of postoperative complications, its concurrent use with tobacco was linked to greater rates of adverse outcomes. Level of Evidence: Level III, retrospective case control study.

Purpose To determine whether long‐term preoperative nonsteroidal anti‐inflammatory drug (NSAID) use affected the revision rates after primary tendon repair for the following common sports medicine surgical procedures: rotator cuff repair (RCR), Achilles tendon repair (ATR), distal biceps repair (DBR), or quadriceps tendon repair (QTR). Methods A retrospective comparative study using a national insurance database was performed. Patients who underwent major tendon repair, including RCR, ATR, DBR, or QTR, with at least 2‐year follow‐up were identified. Those who had a diagnosis of long‐term NSAID use prior to the index operation were identified and matched 1:4 to controls without NSAID use based on age, sex, specific tendon repaired, and Elixhauser Comorbidity Index. The revision repair rates of the 2 groups were compared. Results A total of 36,068 patients underwent major tendon repair. Of these, 7,246 (20%) met the long‐term NSAID use criteria prior to tendon repair (NSAID users). After RCR, 3.2% of NSAID users (n = 190) and 2.6% of controls (n = 617) underwent revision surgery within 2 years (odds ratio [OR], 1.15; 95% confidence interval [CI], 0.97‐1.36; P = .10). After ATR, NSAID users had a revision rate of 3.9% (n = 24) versus 2.5% (n = 62) in the control cohort (OR, 1.47; 95% CI, 0.89‐2.38; P = .12). After DBR, both NSAID users and controls had fewer than 11 revision cases (OR, 1.54; 95% CI, 0.49‐4.16; P = .42). After QTR, the revision rate was 5.9% (n = 30) for NSAID users compared with 4.8% (n = 95) for the control group (OR, 1.22; 95% CI, 0.77‐1.86; P = .38). None of the observed differences in revision rates between NSAID users and controls were significant. Conclusions Patients with a diagnosis of and coding for long‐term preoperative NSAID use do not have greater revision rates within 2 years of primary tendon repair than patients without this diagnosis. Level of Evidence Level III, retrospective case‐control study.

Purpose To assess outcomes of arthroscopic posterior capsular release among athletes for loss of terminal extension following anterior cruciate ligament (ACL) reconstruction. Methods A retrospective review of prospectively collected data was performed for patients undergoing arthroscopic posterior capsular release for knee extension loss following ACL reconstruction between January 2014 and December 2019. Procedure indications included extension loss greater than 10° at least 3 months after ACL reconstruction that was refractory to physical therapy. Patients were included if they were involved in either high school or college athletics, had complete outcomes of interest, and had at least 2 years of follow‐up. Prospectively collected outcomes included preoperative and postoperative measurement of knee extension, International Knee Documentation Committee score, Lysholm score, return to sport data, and complications. Results Eighteen athletes with minimum 2 years of follow‐up who underwent posterior capsular release following ACL reconstruction performed by a single surgeon were included in the analysis. Patients underwent surgery at an average of 16 weeks after ACL reconstruction. Knee extension improved an average of 13.8° at 2 years’ follow‐up (prerelease mean extension deficit 15.1°, postrelease mean extension deficit 1.3°, P < .005). Improvements in the International Knee Documentation Committee score averaged 21.7 at 6 months and 35.0 at 24 months, both of which were statistically significant ( P < .001). Similarly, differences in Lysholm included a significant improvement of 23.0 and 34.2 at 6 months and 2 years, respectively ( P < .001). In total, 77.8% returned to sport at an average of 9.8 months from their primary ACL surgery and 6.5 months following posterior capsular release surgery. No infections or neurovascular complications were observed. One patient required secondary release to achieve adequate extension. Conclusions For athletes with persistent knee extension loss after ACL reconstruction, knee extension was significantly improved at 2 years following arthroscopic posterior capsular release. Substantial improvements in patient‐reported outcomes also were seen. In addition, subjects demonstrated a high rate of return to sport and return to preinjury performance levels. Level of Evidence Level IV, therapeutic case series.

Purpose To evaluate how arthroscopic meniscectomy utilization, reimbursement, physician billing practices, and patient populations have changed within the Medicare population from 2013 to 2021 at a national level and regional level. Methods The Medicare Physician & Other Practitioners database was queried for all episodes of 2‐compartment and single‐compartment arthroscopic meniscectomy between 2013 and 2021. Utilization per 10,000 beneficiaries and average inflation‐adjusted reimbursement were assessed. Physician practice styles, measured through changes in the services billed, and Medicare beneficiary demographic characteristics were extracted each year. The Kruskal‐Wallis test was performed to compare regions. Results Between 2013 and 2021, two‐compartment meniscectomy utilization per 10,000 Medicare beneficiaries declined by 54.9% and single‐compartment meniscectomy utilization declined by 54.2%. Average reimbursement declined by 9.3% and 12.5% for 2‐compartment meniscectomy and single‐compartment meniscectomy, respectively. In 2021, the South had the highest utilization of both 2‐compartment (3.8/10,000) and single‐compartment (4.7/10,000) meniscectomies while having the lowest average reimbursement for 2‐compartment meniscectomy ($383.02, P < .001). Nationally, the average number of beneficiaries per surgeon performing single‐compartment meniscectomy declined by 3.8% whereas the average number of billable services performed per beneficiary increased by 46.6%. The comorbidity risk score of these patients decreased by 8.7%, with the West having the healthiest patients in 2021. Conclusions Meniscectomy utilization and reimbursement have been declining nationally within the Medicare population. Surgeons in the South performed the most meniscectomies while having among the lowest reimbursement. The practice patterns of surgeons performing meniscectomies have been changing, with surgeons performing nearly 50% more total billable services per beneficiary while performing fewer unique billable services. Additionally, the patient population of surgeons who perform meniscectomy was healthier in 2021 than in 2013. Clinical Relevance This study highlights changes in meniscectomy utilization and reimbursement over time in the face of changing evidence of meniscectomy use in elderly patients and new Medicare legislature regarding reimbursement.

Background: While there has been much interest in the increased dislocation rate in total hip arthroplasty (THA) patients with a lumbar spine fusion (LSF), there is minimal literature comparing the risk based on surgical approach. The purpose of this study was to determine if a direct anterior (DA) approach was protective against dislocation when compared to the anterolateral and posterior approaches in this high-risk patient population. Methods: A retrospective review was performed of 6554 THAs performed at our institution from January 2011 to May 2021. 294 (4.5%) patients had a prior LSF and were included in the analysis. The surgical approach, timing of LSF in relation to THA, vertebral levels fused, timing of THA dislocation, and the need for revision surgery were recorded for statistical analysis. Results: In total, 39.7.3% of patients underwent a DA approach (n = 117), 25.9% underwent an anterolateral approach ( n = 76), and 34.3% underwent a posterior approach ( n = 101). There was no difference in number of vertebral levels fused between groups (mean 2.5, all p > 0.05). There was a total of 13 (4.4%) THA dislocation events, with an average time from surgery to dislocation of 5.6 months (0.3–30.5 months). There were fewer dislocations in the DA cohort (0.9%) in comparison to both the anterolateral (6.6%, p = 0.036) and posterior groups (6.9%, p = 0.026). Conclusions: The DA approach demonstrated a significantly lower THA dislocation rate compared to both the anterolateral and posterior approaches in patients with a concomitant LSF.

Bone autografts are frequently harvested for use in foot and ankle surgery. A commonly used harvest site is the iliac crest; however, because of known morbidity with this site, the tibia and calcaneus are attractive alternatives. There remains limited understanding regarding the osteogenic potential of autografts from each of these locations. In this review, we provided an update of the known data on bone autografts from the iliac crest, tibia, and calcaneus, focusing on the total cells harvested from each site as well as the presence of osteogenic osteoprogenitor cells. Level of Evidence: Level V, expert opinion.

Background: The deep peroneal nerve (DPN) plays a role in afferent nociceptive dorsal midfoot joint pain perception. DPN neurectomy for treatment of symptomatic dorsal midfoot osteoarthritis allows early mobilization and weightbearing. The purpose of our study was to evaluate the patient satisfaction and pain relief after DPN neurectomy for treatment of chronic dorsal midfoot pain due to osteoarthritis. Methods: In this retrospective, IRB-approved, questionnaire-based study, we evaluated 48 patients (55 feet) with an average follow-up of 35.1 (range, 16-51) months who underwent DPN neurectomy at our institution between September 2017 and February 2021. There were 38 women and 10 men, 41 unilateral (22 right, 19 left) and 7 bilateral procedures, with an average age of 67.8 (range, 35-88) years at the time of surgery. A questionnaire that included questions regarding postsurgical dorsal midfoot pain relief, surgical result satisfaction, and current functional limitations was administered via telephone. Demographic information, patient responses, and complications were recorded. Results: Of the 48 patients, 80.8% were satisfied with the result of the surgery in relieving their dorsal midfoot pain, 84.6% would repeat the surgery under the same circumstances, 83.8% would recommend the surgery to a friend, 10.4% reported they wish they had undergone arthrodesis, 91.7% reported pain relief in the first 6 months, and 55.6% reported current activity limitations. Six feet (10.9%) underwent a second procedure with an average postoperative time of 20.5 (range, 1-36) months. Complications included 1 hematoma and deep wound infection, 1 DPN neuroma and superficial peroneal nerve entrapment, and 4 patients with inadequate pain relief. Conclusion: In this cohort, DPN neurectomy appeared to be a reasonable surgical alternative to arthrodesis for the management of chronic dorsal midfoot pain due to midfoot osteoarthritis after failed nonoperative management. Level of Evidence: Level IV, retrospective case series.