United States

The Association of Blepharoplasty and Ptosis Repair Surgeries with the Development of Postoperative Dry Eye Syndrome (DES) 

Background
Dry Eye Syndrome (DES) poses a significant ocular health concern globally, leading to pain and visual changes that may persist for several years. This study investigates the incidence and risk factors associated with DES following four different upper eyelid surgeries: Muller&#39;s Muscle-Conjunctival Resection (MMCR), internal levator advancement and resection (internal LAR), external levator advancement and resection (external LAR), and Upper-Eyelid Blepharoplasty (UEB). Considering that these surgeries can affect the orbicularis muscle and lacrimal glands, we hypothesized that patients undergoing any of these surgeries could face an increased risk of developing DES post-operation.

Methods
Analyzing the TriNetX patient health database for surgeries conducted between 2003 and 2023, records of 4,551 patients undergoing MMCR, 4,534 patients undergoing internal LAR, 15,326 patients undergoing external LAR, and 27,696 patients undergoing UEB were examined after application of exclusion criteria. Exclusion criteria included ICD-10 codes for pre-existing DES, Meibomian gland dysfunction, Sjogren syndrome, pterygium, thyroid disease, and diabetes. Analysis encompassed linear regression to identify demographic and medical risk factors associated with post-surgical DES. Propensity score matching (PSM) facilitated pairwise outcome comparisons between the four surgeries. 

Results
Internal LAR (OR: 1.17, 95% CI: (1.057,1.296)) and external LAR ((OR: 1.07, 95% CI: (1.008,1.128)) were strongly associated with the development of postoperative DES. Post-PSM pairwise comparison analysis showed that internal LAR carried a greater risk than external LAR (RR = 1.18; 95% CI: (1.062,1.303)). UEB was strongly associated with a decreased risk of postoperative DES ((OR: 0.89, 95% CI: (0.852,0.924)), while MMCR was not significantly associated with postoperative DES (OR: 1.04, 95% CI: (0.939,1.154)). Among all four surgeries, common risk factors for postoperative DES included osteoarthritis (OA), nicotine dependence (ND), obstructive sleep apnea (OSA), and female gender, while Asian ethnicity was a risk factor only for post-UEB DES. 

Conclusion
Internal LAR and external LAR present increased risk for postoperative DES, with OA, ND, OSA, and female gender significantly influencing DES incidence. Notably, internal LAR presents a heightened risk compared to external LAR. These results can offer valuable insights for patients and healthcare providers deliberating on various ptosis repair procedures, emphasizing the critical need for thorough preoperative evaluations and tailored patient education to mitigate the risk of DES in eyelid surgical interventions.


AMA Research Challenge 2024 

The Association of Blepharoplasty and Ptosis Repair Surgeries with the Development of Postoperative Dry Eye Syndrome (DES)

The Association of Blepharoplasty and Ptosis Repair Surgeries with the Development of Postoperative Dry Eye Syndrome (DES) 

Background
Dry Eye Syndrome (DES) poses a significant ocular health concern globally, leading to pain and visual changes that may persist for several years. This study investigates the incidence and risk factors associated with DES following four different upper eyelid surgeries: Muller's Muscle-Conjunctival Resection (MMCR), internal levator advancement and resection (internal LAR), external levator advancement and resection (external LAR), and Upper-Eyelid Blepharoplasty (UEB). Considering that these surgeries can affect the orbicularis muscle and lacrimal glands, we hypothesized that patients undergoing any of these surgeries could face an increased risk of developing DES post-operation.

Methods
Analyzing the TriNetX patient health database for surgeries conducted between 2003 and 2023, records of 4,551 patients undergoing MMCR, 4,534 patients undergoing internal LAR, 15,326 patients undergoing external LAR, and 27,696 patients undergoing UEB were examined after application of exclusion criteria. Exclusion criteria included ICD-10 codes for pre-existing DES, Meibomian gland dysfunction, Sjogren syndrome, pterygium, thyroid disease, and diabetes. Analysis encompassed linear regression to identify demographic and medical risk factors associated with post-surgical DES. Propensity score matching (PSM) facilitated pairwise outcome comparisons between the four surgeries. 

Results
Internal LAR (OR: 1.17, 95% CI: (1.057,1.296)) and external LAR ((OR: 1.07, 95% CI: (1.008,1.128)) were strongly associated with the development of postoperative DES. Post-PSM pairwise comparison analysis showed that internal LAR carried a greater risk than external LAR (RR = 1.18; 95% CI: (1.062,1.303)). UEB was strongly associated with a decreased risk of postoperative DES ((OR: 0.89, 95% CI: (0.852,0.924)), while MMCR was not significantly associated with postoperative DES (OR: 1.04, 95% CI: (0.939,1.154)). Among all four surgeries, common risk factors for postoperative DES included osteoarthritis (OA), nicotine dependence (ND), obstructive sleep apnea (OSA), and female gender, while Asian ethnicity was a risk factor only for post-UEB DES. 

Conclusion
Internal LAR and external LAR present increased risk for postoperative DES, with OA, ND, OSA, and female gender significantly influencing DES incidence. Notably, internal LAR presents a heightened risk compared to external LAR. These results can offer valuable insights for patients and healthcare providers deliberating on various ptosis repair procedures, emphasizing the critical need for thorough preoperative evaluations and tailored patient education to mitigate the risk of DES in eyelid surgical interventions.


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Background

Anterior cruciate ligament (ACL) reconstruction is a common orthopedic procedure, and patient reported outcome measures (PROMs) are often used to measure long term success of treatment. The study’s goal was to investigate factors associated with clinically meaningful outcomes after ACL reconstruction, as measured by the Patient Acceptable Symptom State (PASS). Additionally, the study aimed to evaluate differences in factors between male and female patients. 


Methods
Patients above the age of 14 who received ACL reconstructions at a single institution were identified retrospectively. Data on demographics, operative notes, and medical history were collected from electronic medical records. These patients were followed up a minimum of two years after surgery with surveys that included an International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form and asked about subsequent diagnoses and surgeries. PASS was defined an IKDC score off 75.9 or higher based on the threshold identified by Muller et al. Univariate logistic regression was performed to identify predictors of achieving PASS, and variables were selected for inclusion in a multivariable logistic regression model based on univariate analysis, prior literature, and clinical relevance. The multivariate regression was stratified by sex. 


Results
A total of 479 patients were included in the study with a mean follow up of 10 ± 5 years. The cohort had an average age of 38 and was 57% female. PASS was achieved by 68% of patients and 9 patients underwent ACL revision surgery. Upon univariate analysis, age, BMI, meniscectomy, revisions and skiing were identified as potential predictors for the multivariable model. Multivariable analysis found that higher BMI (OR 0.95[0.91, 0.99], p = 0.019) and revisions (OR 0.2 [0.04, 0.78], p = 0.025) had independent, negative associations with achievement of PASS. Participation in skiing (OR 1.81 [1.12,2.99], p = 0.018) was found to be positively and independently associated with achieving PASS. Among males, higher BMI (0.9 [0.83, 0.99], p = 0.023) was negatively associated with PASS and participation in skiing (3.52 [1.63, 8.38], p = .002) was positively associated with PASS. Among females, revisions (OR 0.09 [0.00,0.63], p = 0.034) were negatively associated with achievement of PASS. 

Conclusion

Sex differences were observed in factors associated with achieving PASS after ACL reconstruction. Among males, BMI and skiing were found to be associated with PASS, while among females, revision surgery was a significant predictor. These results highlight the need for further investigation of sex specific factors in ACL reconstruction outcomes. 


Sex-specific factors associated with achieving Patient Acceptable Symptom State (PASS) at a mean ten year follow up after anterior cruciate ligament (ACL) reconstruction.

Background
GGS and MCGR are operations aimed to correct and control severe progressive spine deformity while maintaining growth in i-EOS. Past studies yielded similar results between constructs but used vertical coronal measures (e.g. T1-S1), which don’t account for growth outside of plane of measurement due to the spine deformity. This study compares outcomes of GGS and MCGR in i-EOS using 3D-TSL, a validated method that measures spine length in 3D.
Methods
A multi-center database was queried for patients undergoing MCGR / GGS surgery for i-EOS with minimum 2-year follow-up. 31 GGS and 130 MCGR patients were included with measurements at preop, postop, and 2 years. Mixed-model statistics allowed for missing data points and included age group, intervention type, and visit as fixed factors with subject as random. Growth was calculated with paired values; thus growth numbers may not equal change in average values.
Results
There were 161 patients (99 female, 61%) whose mean age at surgery was 8.1 yrs. 19.3% GGS and 8.5% MCGR underwent repeat surgeries within the study period. Age, # of instrumented levels, and preop kyphosis/scoliosis were similar between groups. Total cohort mean scoliosis was 70° preop, 38° postop and 41° at final (p<0.001). GGS reduced the major deformity from 67° to 26° (61 % correction), with a 9° loss of correction at 2 years to 35° (46% correction, p=.02). MCGR reduced the major deformity 71° to 40° (37% correction) but did not significantly lose correction (+2°; final 42°, 34% correction) and was not different from GGS at follow-up. GGS maintained kyphosis perioperatively with increase at 2 years (+8°, p=.004), whereas MCGR decreased at postop (-7°, p<.001) with increase of 6° at final (p=.002). Both groups demonstrated T1-S1 height increase from preop (281 mm) to postop (314 mm) and 2-year (336 mm) (p<.001). 3D-TSL didn’t significantly change perioperatively (338 to 342 mm) for either construct. At 2 years GGS 3D-TSL increased 32.6 mm (16.3 /year), while MCGR increased 27.5 mm (13.8/year) (p=.29).
Conclusion
In i-EOS MCGR and GGS resulted in increase in T1-S1 height preop to postop, but there was no change in 3D-TSL. Postop to Final 3D-TSL identified growth up to 2 years postop in both constructs. T1-S1 height changes suggest that changes in deformity reduce reliability of planar measurements when assessing spine growth. 3D-TSL constitutes a more reliable indicator of spine growth after i-EOS surgery. Overall, GGS and MCGR offer similar outcomes 2 years postop as assessed by 3D- TSL.

3-Dimensional True Spine Length (3D-TSL) In Growth-Guidance Surgery (GGS) vs. Magnetically Controlled Growing Rods (MCGR) for Idiopathic Early Onset Scoliosis (i-EOS)

Background
The “Probable Zone” refers to the area of the hand where the Berrettini Anastomosis (BA) typically occurs. Measuring the dimensions of the BA within the “Probable Zone” is essential for advancing clinical diagnosis, surgical planning, and nerve repair strategies. The BA, an exclusively sensory anastomosis, arises from the communication of common digital nerve three (CDN3) of the median nerve and common digital nerve four (CDN4) of the ulnar nerve near the flexor retinaculum. In previous studies, the prevalence, patterns, and functions of the BA were examined, particularly in carpal tunnel release, where damage to CDN3 can occur. This pilot study expands on the significance of measurements of the BA, delineating the clinical importance of understanding the “Probable Zone.”

Methods
Sample collection was restricted to hands dissected at Tilman J. Fertitta Family College of Medicine and Baylor College of Medicine. With 104 samples, proper identification of the BA required dissection of the median and ulnar nerves' CDN3 and CDN4, and surrounding nerve distributions. Following hand dimension measurements, the determination of the BA allowed for accurate measurement of its dimensions. The hands' lengths were measured from the bistyloid line to the joint of the third digit metacarpophalangeal (MCP), and the width was measured from the second digit MCP to the fifth digit MCP. The BA was measured from its major origin and insertion points. All measurements were collected using a digital caliper.

Results
The BA’s probable zone was calculated using comparative measurements from all reference points. The measured dimensions for the hand size yielded a mean hand length of 79.45 mm and a mean hand width of 68.15 mm. The BA measured a mean length of 22.03 mm (x = 12.34 mm and y = 10.79 mm). The probable zone extends between 36.63% to 50.21% of the hand’s length and between 26.11% to 44.21% of the hand’s width.

Conclusion
This palmar “probable zone” within the hypothenar eminence represents the location where communication patterns are most likely to be found. Previous BA studies have described a similar “reference area” or “risk zone,” although slightly larger than that of the current study. Iatrogenic injury to the BA has been documented in common hand procedures, including carpal tunnel release, ring finger flexor tendon surgery, and Dupuytren’s fasciectomy, reporting symptoms of unpleasant hyperesthesia. Providing precise surface landmarks for clinicians may assist with preoperative preparations to avoid potential BA injury.


A Cadaveric Pilot Study on the 'Probable Zone' of the Berrettini Anastomosis

Background - Multiple autograft choices are available for anterior cruciate ligament reconstruction (ACLR), however the ideal graft choice has not been determined. While there are technical differences, consideration of cost-driving factors that influence ACLR graft choice could help optimize value-based care. This study aims to evaluate the expenses associated with different graft choices for ACLR, considering demographic variables and graft cost. 

Methods – A retrospective chart review was performed from January 2020 to August 2023 for patients undergoing primary ACLR at one health system. All adult patients who have undergone ACL repair surgery within this timeframe were included. Demographic data including sex, age, ethnicity, body mass index (BMI) was collected. Socioeconomic status (SES) was analyzed using median household income (MHI) and area deprivation index (ADI) based on patient addresses (UW-Madison). Graft type and costs were obtained from the electronic medical record. Multiple linear regressions and t-test analyses were performed. 

Results – A total of 389 patients were included with 274 BTB grafts, 64 hamstring grafts, and 51 quad grafts. Mean cost of BTB graft was $3,730.35, hamstring graft was $3,491.43, and quad graft was $4,280.34. Both hamstring and quad grafts were significantly correlated with greater total costs (p=0.018) (p=0.006), while BTB grafts were not (p=0.232). no significant correlations were found between ADI, sex, race, age, insurance type, and smoking and total graft costs. BMI, however, was significantly associated with greater total supply costs (p=0.015). 

Conclusion – Graft selection in ACLR was identified as a modifiable cost driver in this study, with hamstring grafts found to be significantly cheaper and quad grafts significantly more expensive. The average cost is highest when using a quad graft and lowest when using a hamstring graft. BMI also proved to be a contributor to costs in ACLR. 


Anterior Cruciate Ligament Reconstruction Graft Choice Cost Driver Analysis: A Value Based Study

Introduction: As artificial intelligence (AI) continues to gain popularity among patients as an educational resource, it is crucial to understand whether AI can provide reliable information on orthopaedic conditions. While prior studies have investigated the utility of ChatGPT in providing information on common orthopaedic surgeries, they have yet to explore its utility for more rare and complex diseases. This study evaluates the accuracy and comprehensibility of responses produced by ChatGPT to answer common patient questions about osteosarcoma.

Methods: Ten frequently asked questions (FAQs) regarding osteosarcoma were compiled through a literature review and national society patient FAQ pages. ChatGPT (Version 3.5) was subsequently utilized to answer these questions. For each response, a detailed description was written based on relevant literature supporting or refuting the chatbot's claims. Responses were analyzed for accuracy and clarity using a previously validated scoring system for ChatGPT response accuracy and a modified DISCERN score. The responses were independently reviewed by three authors, and scores were averaged as a crowd-sourced scoring strategy. Readability was assessed using five published educational-level indices. FAQ compilation and scoring were completed in collaboration with two fellowship-trained orthopaedic oncology surgeons. 

Results: ChatGPT's responses generally required moderate clarification, with a mean accuracy score of 3 (satisfactory but requiring moderate clarification). One response received a mean rating of 2 (satisfactory requiring minimal clarification), five responses received a rating of 2.5, and four responses received a rating of 3. The 10 responses received an average mean DISCERN score of 36 (classified as poor, 28-38). The interrater reliability between the two orthopaedic oncology surgeons for the DISCERN criteria was 0.601, qualifying as moderate agreement. Readability level ranged from college graduate to 7th grade, exceeding the recommendation for patient educational materials. 

Conclusions: While moderately accurate, most responses regarding osteosarcoma required further clarification and were written at an inaccessible reading level. ChatGPT can therefore be considered a starting point for patient education on osteosarcoma to supplement traditional patient education strategies, but it should not replace professional medical advice. One major limitation of AI that was apparent in the present study is its inability to provide personalized recommendations. The chatbot does not account for varying clinical presentations and degrees of scientific literacy that might affect an individual patient's counseling and treatment options. Future research should apply similar methodologies to other AI platforms to more comprehensively investigate the breadth and accuracy of online resources available to patients.

Assessing the Accuracy of ChatGPT to Answer Commonly Asked Patient Questions about Osteosarcoma

Background:

The posterior compartment of the leg typically contains three muscles in the superficial flexor group: the gastrocnemius, plantaris, and soleus. The gastrocnemius muscle forms the major bulk of the posterior compartment of the leg and is instrumental to walking and posture. The gastrocnemius has medial and lateral heads that originate from the medial and lateral condyles of the femur, respectively. The motor nerve supplying the two gastrocnemius heads is the tibial nerve, receiving fibers from the L5, S1, and S2 nerve roots. The posterior leg is cutaneously supplied by the L4-S2 nerve roots. This biarticular muscle distally inserts into the posterior surface of the broad membranous Achilles tendon. However, a third head of the gastrocnemius, is an extremely rare accessory muscle bundle of the gastrocnemius muscle that covers the surface of the popliteal fossa. There has been scarce representation in the literature of bilateral gastrocnemius tertius muscles.


Case Presentation:

In this poster, we present a case report of bilateral anomalous gastrocnemius tertius muscles discovered in a 67-year-old male cadaveric who died of complications related to vascular dementia. Upon routine educational dissection of the cadaver, an extra muscle belly was discovered bilaterally, medial to each gastrocnemius lateral heads, which was determined to be tertius heads of the gastrocnemius muscle. The tertius heads were separated from the gastrocnemius medial and lateral heads by a fascial sheath. Muscle fibers were arranged in a unipennate pattern. The tertius heads attached proximally to the lateral condyle of the femur – at the same attachment point of the lateral head – and distally contributed to the Achilles tendon. The belly length was 24 cm, and width was 2.5 cm. The tertius head muscles were both innervated by a unique branch of the tibial nerve that entered the muscle belly. Vasculature to the tertius heads originated from additional branches of the popliteal artery and veins. The proximal tendon and belly of this muscle were in proximity to the tibial nerve and artery. 


Discussion: 

The gastrocnemius is a powerful plantar flexor and knee flexor. Therefore, this muscle provides significant propulsive force regarding gait mechanics. Anomalies of this muscle bundle is important to recognize as they can have significant implications on future patient outcomes. To our knowledge, bilateral gastrocnemius tertius muscles have only been reported in literature once before. Although believed to be a benign anatomical variant, this can potentially lead to pathologies such as Popliteal Artery Entrapment Syndrome, sural nerve entrapment, and deep vein thrombosis. Compression of these structures by the tertius head may cause numbness, tingling, swelling, and signs of muscle hypoxia in the posterior leg. Therefore, clinicians should be aware of this variant and its clinical relevance. Tertius head-related posterior leg vessel compression should be considered on differential when treating patients with signs and symptoms of popliteal fossa swelling and pain. Finally, it could give rise to future reports with similar presentations that lead to better understanding of the physiology of this anomaly.


Bilateral Gastrocnemius Tertius: A Rare Cadaveric Finding

Background: 
Anterior cruciate ligament reconstruction (ACLR) is frequently recommended to restore the knee's mechanical function after ACL injury. Autograft options include the bone-patellar tendon-bone (BTB) and quadriceps tendon (QT) grafts. A recent study reported that QT grafts result in larger quadriceps strength deficits than BTB grafts at seven months post-ACLR. These deficits may implicate persistent functional deficits, development of osteoarthritis, and/or subsequent ACL injury. However, there is a knowledge gap regarding longitudinal outcomes of quadriceps strength between these grafts. Therefore, this study aimed to provide preliminary evidence on the effect of graft type (BTB vs. QT) on isokinetic quadriceps strength within the first year post-ACLR. It was hypothesized that BTB would demonstrate greater improvements than QT over time.

Methods: 
Twenty-three subjects were consented and tested in this ongoing IRB-approved prospective clinical trial (BTB: n=10, BMI=27.7±5.3 kg/m2, ages 19.6±5.3 years; QT: n=13, BMI=22.9 ± 5.0 kg/m2, ages 18.3±5.0 years). All patients followed a similar rehabilitation program.
Concentric isokinetic leg strength was assessed using a Humac Norm dynamometer (CSMi) during knee extension. The test was first conducted on the unoperated knee, followed by the ACLR knee. After a standardized warm-up, participants performed five maximal effort repetitions at 60°/s. The outcome measures included peak torque (PT), average work per repetition (W), and average power per repetition (P). The percent deficits between limbs were analyzed using a repeated measures analysis of variance (α=0.05) for time (6 vs. 12 months) and graft type (BTB vs. QT).

Results: 
In BTB patients, deficits were significantly reduced in PT (mean difference(Δ)=-29.38±6.64 N, p<0.01), W (Δ=-22.75±7.97 J, p=0.01), and P (Δ=-26.25±6.51 W, p<0.01), while no reduction was detected in QT patients in these measures (PT: Δ=-2.78±6.18 N, p=0.66; W: Δ=1.10±7.42 J, p=0.88; P: Δ=0.22±6.06 W, p=0.97).

Conclusion: 
By 12 months, participants with BTB showed greater improvements in quadriceps strength deficits than those with QT, supporting the study hypothesis. These findings are critical as strength deficit reduction correlates with better long-term knee function.
This result may be attributed to a lack of graft-specific rehabilitation regimens, as studies have indicated that QT-specific rehabilitation can reduce strength deficits post-ACLR. Additionally, QT harvesting occurs at the quadriceps tendon, which has a more direct role in the knee extensor mechanism and potentially has a greater impact on strength deficits.
These findings strongly motivate further research with longer follow-ups and larger sample sizes in order to provide more confident conclusions on how to improve rehabilitation programs by graft type.

Bone-Tendon-Bone Yields Greater Quadriceps Strength Improvement Than Quadriceps Tendon after ACL-Reconstruction

Background
Inlay total shoulder arthroplasty (iTSA) serves as a stemless shoulder reconstruction option. While current literature has demonstrated improved patient reported outcomes (PROs) with minimal postoperative revisions and high rates of return to activity, supporting long-term evidence is limited. The purpose of this study was to evaluate the trends in PROs following iTSA over an eleven-year period.

Methods
A historical cohort of our institutional database was used to investigate outcome trends. Inclusion criteria consisted of patients with advanced osteoarthritis treated with iTSA. Patients had preoperative PROs and a minimum of one follow-up assessment between 1-11 years. Outcomes assessments included WOOS%, ASES, activities of daily living (ADLs), VAS pain, patient satisfaction, and range of motion (ROM). Descriptive analyses were conducted using Stata (v.15, College Station, TX). Join-point regression analysis (version 5.0.2, National Cancer Institute) was used to explore trends in functional outcomes, pain relief, and ADLs to determine whether a change in temporal trend was statistically significant. WOOS%, ASES, ADLs, and VAS pain were entered into the model and were assessed at five timepoints: preoperative, 1 year, 2-3 years, 4-7 years, and 8-11 years.

Results
Since 2011, 583 shoulders were treated with iTSA at our institution and 97 met the inclusion criteria, with 10 patients being bilateral. The mean age was 63.7 years ± 10.5 (31 females, 66 males). The average length of follow-up was 60.5 months ± 37.8. Along the postoperative period of up to 2-3 years, there was significant improvement in WOOS% (84.97 AYPPC), ASES (78.22 AYPPC), and VAS pain (-74.50 AYPPC), after which gains were sustained. ADLs improved over time, but there was no significant change in the trend. The median PROs improved at all five timepoints: WOOS% [26(16-40), 85(56-95), 93(77-97), 89(75-97), 92(77-97)], ASES [27(17-40), 83(67-93), 88(68-95), 87(70-97), 90(78-98)], VAS pain [8(6-9), 1(0-3), 1(0-2), 0(0-3), 0(0-0)] and ADLs [4(2-6), 8(6-10), 9(6-10), 8(6-8), 9(6-10)]. Mean ROM improved by 46.49 degrees ± 37.28 on forward elevation and 26.95 degrees ± 18.90 on external rotation.  Mean patient satisfaction on a scale of 1-10 (10=best) for each follow-up timepoint was 8.6 ± 2.4, 9.2 ± 1.6, 8.7 ± 1.8, and 9.6 ± 0.7 respectively (p <0.001). 

Conclusion
iTSA demonstrated significant improvement in pain relief and functional outcomes within 2-3 years, after which gains were sustained over an eleven-year period. ROM improved and patient satisfaction remained high over time. These findings support the use of stemless shoulder reconstruction as a reliable solution for advanced shoulder osteoarthritis.

Clinical Improvements After Inlay Total Shoulder Arthroplasty are Sustained: A Long-term Follow-up Trending Analysis

Background

In recent years, the use of 3-dimensional (3D) printing in orthopedic surgery has greatly expanded, including the application of 3D-printed implants following bone tumor excision. After complete bone tumor excision, bone defects are typically reconstructed and implanted with a prosthetic. Historically, commercially produced implants have been used, but recent research explores the benefit of individualized 3D-printed prostheses (3DPs). These custom implants more accurately match the complex shapes of orthopedic defects and are especially useful in areas where unusual implants are necessary. The purpose of this review is to compile the available literature surrounding 3D-printed bone tumor prostheses and use patient outcomes to evaluate the efficacy of 3DPs compared to conventional prostheses. This review aims to assess the benefits and limitations of 3DPs and determine if they are a viable alternative to traditional implants.

Methods:
A systematic review was conducted, and the literature search was limited to studies with a comparable non-3DP control. A variety of bone tumor types and locations were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied. Outcome measures of 3DPs and conventional implants were compared in the context of the tumor location and procedure type. The selected outcome measures include operative duration, intraoperative blood loss, hospital stay, cost, complication rate, implant dislocation, and Musculoskeletal Tumor Society Scoring System (MSTS) score.

Results

Operative duration was decreased with 3DP use in 4 studies of pelvic and periacetabular tumors, with a reduction of 125, 70, 63, and 41 minutes respectively. Conversely, thoracolumbar 3DPs showed an average increased operative duration of 54 minutes. Compared to control, reduced intraoperative blood loss was seen in pelvic, periacetabular, and thoracolumbar 3DP procedures. MSTS score, a quality of life measure, was improved in the 3DP group compared to control in all four studies of pelvic and periacetabular tumors. In two cases of pelvic tumors, the 3DP group demonstrated an average decreased risk of implant dislocation by 11.22%. In thoracolumbar tumors, the risk decreased by 7.2%.

Conclusion

Compared to conventional controls, our review demonstrates the benefits of 3DPs in improving patient outcomes and the efficiency of surgical procedures. Intraoperative blood loss, complication rate, and implant dislocation occurrence were all shown to be reduced with the use of 3DPs. 3DP use also revealed an improvement in MSTS score and tumor resection accuracy. Additional studies with comparable controls are necessary to further evaluate the benefits of 3DPs and assess their long-term efficacy.

Clinical Outcomes of the Use of 3-Dimensional Printing Implants in Cases of Bone Tumors: A Meta-Analysis

Abstract Title
Comparison of Clinical Outcomes in Patients with Primary Versus Ipsilateral Revision ACL Reconstruction

Background
Up to 30% of young active patients with a previous anterior cruciate ligament reconstruction (ACLR) suffer a second ACL rupture within the first two years after surgery. To our knowledge, few studies have determined if individuals who undergo a second ACLR report worse knee function and psychological response to injury recovery when compared to individuals who undergo primary ACLR. The aim of this study is to investigate whether there is a difference in functional and psychological outcomes in patients who have undergone an ipsilateral revision ACL reconstruction compared to patients with a primary ACL reconstruction. 

Methods
Data were combined from ongoing retrospective and prospective cohort studies at a single medical center. Patients were included in this study if they were 13-40 years old, underwent primary uncomplicated ACLR or ipsilateral revision ACLR at our institution, and participated in our standardized return to sport testing protocol at least 5 months post-ACLR. Patients were excluded if they experienced perioperative complications that resulted in a delayed standard of care. Surgical characteristics were confirmed via chart review. Primary outcomes of interest included knee function measured by the International Knee Documentation Committee Subjective Knee Evaluation score (IKDC), psychological readiness for return to sport measured by the ACL-RSI score, and isokinetic (60°/s) quadriceps and hamstring strength limb symmetry index (%). Patient-reported and strength outcomes were compared between patients in the primary and revision ACLR groups using ANCOVA while controlling for the effects of age and time since surgery. A-priori alpha level was established as p < 0.05. 

Results
Patients in the primary ACLR group were younger (p=0.002) and the groups also differed based on graft source (p=0.013), and medial meniscus (p=0.041) treatment (meniscectomy, repair, or no treatment) at the time of ACLR. After accounting for time since surgery and age, there were no significant differences between groups for IKDC score (p=0.740), ACL-RSI score (p=0.762), nor knee extension strength LSI (p=0.393); however, the primary ACLR group displayed greater knee flexion strength LSI (p=0.020). 

Conclusion
Patients that underwent revision ACLR had similar outcomes in terms of patient-reported psychological readiness to return to sport, patient-reported knee function, and knee extension strength compared to those who underwent primary ACLR. However, the revision ACLR group demonstrated decreased knee flexion strength. This finding may suggest that patients undergoing recovery from revision ACLR may benefit from increased incorporation of hamstring-specific strength building exercises during rehabilitation to restore knee flexion function and prevent future injury.

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