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Meniscus root injuries lead to increased tibiofemoral contact pressures and rapid progression of osteoarthritis. Early recognition and treatment with a meniscal root repair can restore biomechanics and help preserve the joint. The transtibial pullout repair and suture anchor repair are the most commonly used techniques to achieve anatomic fixation of the meniscal root. Still, each method presents distinct advantages and disadvantages. This Technical Note aims to describe a vastly simplified, more efficient, and reproducible posterior lateral meniscal root repair using a retensionable knotless all-suture anchor.
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Tibial spine avulsion injuries, including fractures, are a variant of anterior cruciate ligament injuries. Treatment historically consisted of open reduction and internal fixation of the avulsion fracture, with anterior cruciate ligament reconstruction considered in cases of failed open reduction and internal fixation or residual laxity. However, improved instrumentation has led to the advancement of various arthroscopic techniques for addressing these injuries. The emergence of newer implants designed for all-suture fixation has also overcome the limitations associated with screw fixation, such as hardware-related complications, challenges in treating comminuted fractures, and potential physeal injury. The purpose of this article is to describe a technique consisting of arthroscopic-assisted reduction and internal fixation of a tibial spine avulsion fracture with a re-tensionable all-suture-based construct using multiple looped cinch stitches and a cortical suspensory suture button device.
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PURPOSE OF REVIEW: The tibial tubercle osteotomy (TTO) is a versatile surgical technique used to treat a range of patellofemoral disorders, including patellar instability, painful malalignment, focal chondral defects, and patellar maltracking that have failed conservative therapies. TTO is a personalized procedure that can be tailored to the pathoanatomy of the patient based on physical examination and imaging. The complication rate associated with TTO strongly depends on the indication for surgery, the severity of the patient's condition, and the surgical approach. Despite the literature on TTO, to our knowledge, no single source has addressed the indications, techniques, outcomes, and complications of this procedure. The purpose of this article is to serve as such a valuable resource. RECENT FINDINGS: Highlights from recent studies we would like to emphasize are two-fold. First, maintaining a distal cortical hinge yields lower complication rates than osteotomies involving complete tubercle detachment with classic or standard techniques. Second, based on current evidence, TTO consistently provides symptomatic relief, and most patients can return to work or sport at their pre-operative level within 3 and 6 months, respectively. TTO is a personalizable surgical technique that may be utilized for multiple patellofemoral disorders and is associated with good outcomes.
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BACKGROUND: While insurance is integral for accessing healthcare in the US, coverage alone may not ensure access, especially for those publicly insured. Access barriers for Medicaid-insured patients are rooted in social drivers of health, insurance complexities in the setting of managed care plans, and federal- and state-level policies. Elucidating barriers at the health system level may reveal opportunities for sustainable solutions. METHODS: To understand barriers to ambulatory care access for patients with Medi-Cal (California's Medicaid program) and identify improvement opportunities, we performed a qualitative study using semi-structured interviews of a referred sample of clinicians and administrative staff members experienced with clinical patient encounters and/or completion of referral processes for patients with Medi-Cal (n = 19) at a large academic medical center. The interview guide covered the four process steps to accessing care within the health system: (1) scheduling, (2) referral and authorization, (3) contracting, and (4) the clinical encounter. We transcribed and inductively coded the interviews, then organized themes across the four steps to identify perceptions of barriers to access and improvement opportunities for ambulatory care for patients with Medi-Cal. RESULTS: Clinicians and administrative staff members at a large academic medical center revealed barriers to ambulatory care access for Medi-Cal insured patients, including lack of awareness of system-level policy, complexities surrounding insurance contracting, limited resources for social support, and poor dissemination of information to patients. Particularly, interviews revealed how managed Medi-Cal impacts academic health systems through additional time and effort by frontline staff to facilitate patient access compared to fee-for-service Medi-Cal. Interviewees reported that this resulted in patient care delays, suboptimal care coordination, and care fragmentation. CONCLUSIONS: Our findings highlight gaps in system-level policy, inconsistencies in pursuing insurance authorizations, limited resources for scheduling and social work support, and poor dissemination of information to and between providers and patients, which limit access to care at an academic medical center for Medi-Cal insured patients. Many interviewees additionally shared the moral injury that they experienced as they witnessed patient care delays in the absence of system-level structures to address these barriers. Reform at the state, insurance organization, and institutional levels is necessary to form solutions within Medi-Cal innovation efforts.
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Acessibilidade aos Serviços de Saúde , Medicaid , Pesquisa Qualitativa , Humanos , Estados Unidos , California , Masculino , Feminino , Entrevistas como Assunto , Assistência AmbulatorialRESUMO
Key terms: Multicontrast and Multiparametric, Magnetic Resonance Imaging, Osteoarthritis, Functional Biomechanical Imaging, Knee Joint Degeneration What is known about the subject: dualMRI has been used to quantify strains in a healthy human population in vivo and in cartilage explant models. Previously, OA severity, as determined by histology, has been positively correlated to increased shear and transverse strains in cartilage explants. What this study adds to existing knowledge: This is the first in vivo use of dualMRI in a participant demographic post-ACL reconstruction and at risk for developing osteoarthritis. This study shows that dualMRI-derived strains are more significantly correlated with patient-reported outcomes than any MRI relaxometry metric. Background: Anterior cruciate ligament (ACL) injuries lead to an increased risk of osteoarthritis, characterized by altered cartilage tissue structure and function. Displacements under applied loading by magnetic resonance imaging (dualMRI) is a novel MRI technique that can be used to quantify mechanical strain in cartilage while undergoing a physiological load. Purpose: To determine if strains derived by dualMRI and relaxometry measures correlate with patient-reported outcomes at six months post unilateral ACL reconstruction. Study Design: Cohort study. Methods: Quantitative MRI (T2, T2*, T1ρ) measurements and transverse, axial, and shear strains were quantified in the medial articular tibiofemoral cartilage of 35 participants at six-months post unilateral ACL reconstruction. The relationships between patient-reported outcomes (WOMAC, KOOS, MARS) and all qMRI relaxation times were quantified using general linear mixed-effects models. A combined best-fit multicontrast MRI model was then developed using backwards regression to determine the patient features and MRI metrics that are most predictive of patient-reported outcome scores. Results: Higher femoral strains were significantly correlated with worse patient-reported functional outcomes. Femoral shear and transverse strains were positively correlated with six-month KOOS and WOMAC scores, after controlling for covariates. No relaxometry measures were correlated with patient-reported outcome scores. We identified the best-fit model for predicting WOMAC score using multiple MRI measures and patient-specific information, including sex, age, graft type, femoral transverse strain, femoral axial strain, and femoral shear strain. The best-fit model significantly predicted WOMAC score (p<0.001) better than any one individual MRI metric alone. When we regressed the model-predicted WOMAC scores against the patient-reported WOMAC scores, we found that our model achieved a goodness of fit exceeding 0.52. Conclusions: This work presents the first use of dualMRI in vivo in a cohort of participants at risk for developing osteoarthritis. Our results indicate that both shear and transverse strains are highly correlated with patient-reported outcome severity could serve as novel imaging biomarkers to predict the development of osteoarthritis.
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Anterior cruciate ligament (ACL) tears are among the most common injuries to the knee. With recent improvements in imaging that allow for more precise identification of ACL tear patterns, improved techniques for repair, and advancements in biological augmentation, there has been a re-emerging interest in primary ACL repair, especially for acute proximal ACL tears. This article aims to describe a surgical technique for primary ACL repair using a re-tensionable all-suture-based construct.
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Bucket-handle meniscus tears alter knee biomechanics and significantly elevate the risk of osteoarthritis when the tissue is not preserved. Consequentially, meniscus repair is preferred whenever possible to optimize load distribution and knee stability, with the overall goal of joint preservation. Bucket-handle meniscus tears have a higher rate of repair failure compared with many other tear patterns, and both the inside-out (IO) and all-inside (AI) techniques are acceptable options, each with distinct advantages and disadvantages. Both have demonstrated improved clinical outcomes with similar failure rates. IO is cost-effective and allows less meniscal trauma due to small-diameter needles, whereas disadvantages include increased surgical time, increased risk of infection, and the need for 1 or more skilled assistants. AI avoids extra incisions and extra assistants and shows decreased surgical time, whereas complications can include hardware irritation, chondral and neurovascular injury (particularly for posterolateral repairs), and motion loss. Hybrid repair using AI for posterior tears and IO for middle-third and outside-in for the anterior meniscus is cost-effective and efficacious. Biologics to promote healing through mechanical stimulation of the tear surfaces, notch marrow venting, trephination, and/or platelet-rich plasma can optimize the repair.
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PURPOSE: To establish consensus statements on platelet-rich plasma (PRP) for the treatment of musculoskeletal pathologies. METHODS: A consensus process on the treatment of PRP using a modified Delphi technique was conducted. Thirty-five orthopaedic surgeons and sports medicine physicians participated in these consensus statements on PRP. The participants were composed of representatives of the Biologic Association, representing 9 international orthopaedic and musculoskeletal professional societies invited due to their active interest in the study of orthobiologics. Consensus was defined as achieving 80% to 89% agreement, strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: There was consensus on 62% of statements about PRP. CONCLUSIONS: (1) PRP should be classified based on platelet count, leukocyte count, red blood count, activation method, and pure-plasma versus fibrin matrix; (2) PRP characteristics for reporting in research studies are platelet count, leukocyte count, neutrophil count, red blood cell count, total volume, the volume of injection, delivery method, and the number of injections; (3) the prognostic factors for those undergoing PRP injections are age, body mass index, severity/grade of pathology, chronicity of pathology, prior injections and response, primary diagnosis (primary vs postsurgery vs post-trauma vs psoriatic), comorbidities, and smoking; (4) regarding age and body mass index, there is no minimum or maximum, but clinical judgment should be used at extremes of either; (5) the ideal dose of PRP is undetermined; and (6) the minimal volume required is unclear and may depend on the pathology. LEVEL OF EVIDENCE: Level V, expert opinion.
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Plasma Rico em Plaquetas , Humanos , Injeções , Contagem de LeucócitosRESUMO
Posterior labral tears are a source of pain and instability of the shoulder. Despite being relatively uncommon (reported in approximately 10% of instability cases), the incidence of posterior labral tear is increasingly recognized as underestimated in highly active populations. Posterior labral tears can result from a traumatic posterior dislocation or repetitive microtrauma, leading to posterior chondral/labral attrition. Patients often present with vague, deep-seated shoulder discomfort rather than the sensation of instability. Unfavorable results with nonsurgical management will indicate which patients will most benefit from surgery. Arthroscopic stabilization has proven to be an effective and reliable treatment, and many techniques for posterior labral repair have been described. It is important to highlight the evaluation, preparation, and execution of arthroscopic stabilization of an isolated posterior labral repair using high-strength knotless all-suture anchors to allow for a stable, efficient, reproducible, and reliable repair while maintaining a low-profile construct that minimizes damage to the surrounding tissue.
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Luxações Articulares , Instabilidade Articular , Lesões do Ombro , Articulação do Ombro , Humanos , Articulação do Ombro/cirurgia , Instabilidade Articular/etiologia , Instabilidade Articular/cirurgia , Artroscopia/efeitos adversos , Artroscopia/métodos , Lesões do Ombro/cirurgia , Lesões do Ombro/complicações , Luxações Articulares/complicaçõesRESUMO
Acromioclavicular joint separations are common shoulder injuries that require prompt recognition, diagnosis, and treatment. Deciding on a treatment algorithm relies on a detailed knowledge of anatomy and a thorough understanding of the specific functional demands of the patient in question. When a repair or reconstruction is indicated, arthroscopic assistance can be a helpful tool to ensure a safe, anatomic reconstruction that minimizes morbidity and maximizes the potential return to high-level function.
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Articulação Acromioclavicular , Lesões do Ombro , Humanos , Articulação Acromioclavicular/cirurgia , Ligamentos Articulares/cirurgia , Algoritmos , Lesões do Ombro/cirurgiaRESUMO
Incomplete healing and/or functional failure following rotator cuff tear repair remains a challenging problem for both patients and surgeons. Augmentation strategies are growing to increase healing through biologic and mechanical mechanisms to improve functional results after arthroscopic rotator cuff repair. The majority of currently described augmentation techniques use allograft tissue. An alternative, low-cost, autograft option for augmentation is the use of the long head of biceps tendon autograft as a free functional graft. Here, we describe the use of autograft biceps tendon as a viable option for augmentation of double-row rotator cuff repair with knotless all-suture suture anchors.
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Isolated posterior instability is well described but relatively uncommon, accounting for less than 10% of all shoulder instability cases. When nonoperative management fails, surgical outcomes demonstrate improved patient-reported outcomes with a high level of return to sport. Knotless suture anchor and "all-suture" suture anchor technology are now available and used for instability procedures in the shoulder. This technical description describes knotless "all-suture" suture anchor fixation for isolated posterior labral tears.
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Osteochondral and pure chondral lesions of the knee are common after patellar dislocations. There are multiple described techniques for the fixation of these lesions, including metallic screws, bioabsorbable screws, bioabsorbable implants, and suture devices. The purpose of this article is to describe a surgical technique for surgical fixation of a lateral condyle chondral lesion using knotless all-suture anchors, with second-look knee arthroscopy illustrating healing of the cartilage repair.
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The foundation of preventing and treating an on-field emergency is preparation and readiness. The sideline medical team should coordinate the utilization of an emergency action plan (EAP). A successful EAP is accomplished through attention to detail, rehearsal, and self-assessments. Every EAP should include site-specific implementation, personnel, equipment, communication, transportation, venue location, emergency care facilities, and documentation. Improvements and advancements can be made to the EAP by self-evaluation after each on-field emergency and yearly reviews. A competent sideline emergency medical team can enjoy the competition while being ready to respond to a catastrophic on-field emergency.
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Serviços Médicos de Emergência , Medicina Esportiva , Esportes , Humanos , EmergênciasRESUMO
Shoulder instability is the separation of the humeral head from the glenoid. Injury to the static and dynamic stabilizers can result in instability. Anterior shoulder instability is the predominant form of instability. It is usually a result of trauma. Posterior shoulder instability often presents with an insidious onset of pain. Multidirectional instability of the shoulder is symptomatic laxity in more than one plane of motion. The primary goal of rehabilitation is to restore pain-free mobility, strength, and functioning. Rehabilitation implements range of motion and strengthening exercises to restore proprioceptive control and scapular kinematics.
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Instabilidade Articular , Articulação do Ombro , Humanos , Ombro , Instabilidade Articular/terapia , Escápula , Modalidades de Fisioterapia , Amplitude de Movimento Articular , Fenômenos BiomecânicosRESUMO
BACKGROUND: The COVID-19 era has been characterized by the politicization of health-related topics. This is especially concerning given evidence that politicized discussion of vaccination may contribute to vaccine hesitancy. No research, however, has examined the content and politicization of legislator communication with the public about vaccination during the COVID-19 era. OBJECTIVE: The aim of this study was to examine vaccine-related tweets produced by state and federal legislators during the COVID-19 era to (1) describe the content of vaccine-related tweets; (2) examine the differences in vaccine-related tweet content between Democrats and Republicans; and (3) quantify (and describe trends over time in) partisan differences in vaccine-related communication. METHODS: We abstracted all vaccine-related tweets produced by state and federal legislators between February 01, 2020, and December 11, 2020. We used latent Dirichlet allocation to define the tweet topics and used descriptive statistics to describe differences by party in the use of topics and changes in political polarization over time. RESULTS: We included 14,519 tweets generated by 1463 state legislators and 521 federal legislators. Republicans were more likely to use words (eg, "record time," "launched," and "innovation") and topics (eg, Operation Warp Speed success) that were focused on the successful development of a SARS-CoV-2 vaccine. Democrats used a broader range of words (eg, "anti-vaxxers," "flu," and "free") and topics (eg, vaccine prioritization, influenza, and antivaxxers) that were more aligned with public health messaging related to the vaccine. Polarization increased over most of the study period. CONCLUSIONS: Republican and Democratic legislators used different language in their Twitter conversations about vaccination during the COVID-19 era, leading to increased political polarization of vaccine-related tweets. These communication patterns have the potential to contribute to vaccine hesitancy.
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In the face of an ongoing opioid crisis in the United States, persistent treatment gaps exist for vulnerable populations. Among the 3 Food and Drug Administration-approved medications used to treat opioid use disorder, many patients prefer buprenorphine. But physicians are currently required to register with the Drug Enforcement Administration and complete 8 hours of qualifying training before they can receive a waiver to prescribe buprenorphine to their patients. In this article, the authors summarize the evolution of buprenorphine waiver training in undergraduate medical education and outline 2 potential paths to increase buprenorphine treatment capacity going forward: the curriculum change approach and the training module approach. As part of the 2018 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, the Substance Abuse and Mental Health Services Administration has provided funding for medical schools to adapt their curricula to meet waiver training requirements. To date, however, only one school has had its curriculum approved for this purpose. Additionally, recent political efforts have been directed at eliminating aspects of the waiver training requirement and creating a more direct path to integrating waiver qualification into undergraduate medical education (UME). Other medical schools have adopted a more pragmatic approach involving the integration of existing online, in-person, and hybrid waiver-qualifying training modules into the curricula, generally for fourth-year students. This training module approach can be more rapidly, broadly, and cost-effectively implemented than the curriculum change approach. It can also be easily integrated into the online medical curricula that schools developed in response to the COVID-19 pandemic. Ultimately both curricular changes and support for student completion of existing training modules should be pursued in concert, but focus should not be single-mindedly on the former at the expense of the latter.
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Buprenorfina/uso terapêutico , Currículo/tendências , Educação de Graduação em Medicina/organização & administração , Antagonistas de Entorpecentes/uso terapêutico , Entorpecentes/uso terapêutico , Faculdades de Medicina/estatística & dados numéricos , Analgésicos Opioides/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Estados UnidosRESUMO
Importance: Mortality across US counties varies considerably, from 252 to 1847 deaths per 100â¯000 people in 2018. Although patient satisfaction with health care is associated with patient- and facility-level health outcomes, the association between health care satisfaction and community-level health outcomes is not known. Objective: To examine the association between online ratings of health care facilities and mortality across US counties and to identify language specific to 1-star (lowest rating) and 5-star (highest rating) reviews in counties with high vs low mortality. Design, Setting, and Participants: This retrospective population-based cross-sectional study examined reviews and ratings of 95â¯120 essential health care facilities across 1301 US counties. Counties that had at least 1 essential health care facility with reviews available on Yelp, an online review platform, were included. Essential health care was defined according to the 10 essential health benefits covered by Affordable Care Act insurance plans. Main Outcomes and Measures: The mean rating of essential health care facilities was calculated by county from January 1, 2015, to December 31, 2019. Ratings were on a scale of 1 to 5 stars, with 1 being the worst rating and 5 the best. County-level composite measures of health behaviors, clinical care, social and economic factors, and physical environment were obtained from the University of Wisconsin School of Medicine and Public Health County Health Rankings database. The 2018 age-adjusted mortality by county was obtained from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiological Research database. Multiple linear regression analysis was used to estimate the association between mean facility rating and mortality, adjusting for county health ranking variables. Words with frequencies of use that were significantly different across 1-star and 5-star reviews in counties with high vs low mortality were identified. Results: The 95â¯120 facilities meeting inclusion criteria were distributed across 1301 of 3142 US counties (41.4%). At the county level, a 1-point increase in mean rating was associated with a mean (SE) age-adjusted decrease of 18.05 (3.68) deaths per 100â¯000 people (P < .001). Words specific to 1-star reviews in high-mortality counties included told, rude, and wait, and words specific to 5-star reviews in low-mortality counties included Dr, pain, and professional. Conclusions and Relevance: This study found that, at the county level, higher online ratings of essential health care facilities were associated with lower mortality. Equivalent online ratings did not necessarily reflect equivalent experiences of care across counties with different mortality levels, as evidenced by variations in the frequency of use of key words in reviews. These findings suggest that online ratings and reviews may provide insight into unequal experiences of essential health care.
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Crowdsourcing/métodos , Instalações de Saúde/normas , Mortalidade/tendências , Satisfação do Paciente , Adulto , Estudos Transversais , Crowdsourcing/estatística & dados numéricos , Feminino , Instalações de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados UnidosRESUMO
During the COVID-19 pandemic many IBD units chose Budesonide MMX (Cortiment) as the first-line treatment for flares of ulcerative colitis (UC) in outpatients for its favourable side effect profile. This retrospective study of all UC patients treated with oral steroids between 1 March 2019-30 June 2019 and 1 March 2020-30 June 2020 aimed to compare Cortiment with Prednisolone in routine clinical practice. Outcomes included the need for hospitalisation for acute severe ulcerative colitis, symptoms at four weeks and end of treatment, and the need for rescue Prednisolone. The 2019 and 2020 cohorts did not differ at the baseline. Cortiment prescriptions rose from 24.5% in 2019 to 70.1% in 2020 (p < 0.001). At week four there were significant differences between 2019 and 2020 in mean bowel frequency (3.49 vs. 5.85, p = 0.001), rectal bleeding <50% (89.7% vs. 73.1% of patients, p = 0.039), and physician global assessment (PGA) (39.2% vs. 19.8% in remission, p = 0.045). There was no significant difference in hospital admissions, rectal bleeding, and PGA at week eight. Rescue Prednisolone was required in 10% of Cortiment patients in 2019 vs. 31.3% in 2020 (p = 0.058). Active IBD is associated with worse COVID-19 outcomes prompting the careful evaluation of the choice of first-line steroid for UC, as Cortiment was associated with worse outcomes at four weeks.
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OBJECTIVE: Previous studies indicate that patients' satisfaction with mental health care is correlated with both treatment outcomes and quality of life. The aims of this study were to describe online reviews of mental health treatment facilities, including key themes in review content, and to evaluate the correlation between narrative review themes, facility characteristics, and review ratings. METHODS: United States National Mental Health Services Survey (N-MHSS) facilities were linked to corresponding Yelp pages, created between March 2007 and September 2019. Correlations between review ratings and both machine learning-generated latent Dirichlet allocation topics and N-MHSS-reported facility characteristics were measured by using Spearman's rank-order correlation coefficient. Significance was defined by a Bonferroni-adjusted p<0.001. RESULTS: Of 10,191 unique mental health treatment facilities, 1,383 (13.6%) had relevant Yelp pages with 8,133 corresponding reviews. The number of newly reviewed facilities and the number of new reviews increased throughout the study period. Narrative topics positively correlated with review ratings included caring staff (Spearman's ρ=0.39) and nonpharmacologic treatment (ρ=0.16). Topics negatively correlated with review ratings included rude staff (ρ=-0.14) and safety and abuse (ρ=-0.14). Of 126 N-MHSS survey items, 11 were positively correlated with review rating, including "outpatient mental health facility" (ρ=0.13), and 33 were negatively correlated with review rating, including accepting Medicare (ρ=-0.21). CONCLUSIONS: Narrative topics provide information beyond what is currently collected through the N-MHSS. Topics associated with positive and negative reviews, such as staff attitude toward patients, can guide improvement in patients' satisfaction and engagement with mental health care.