Golfing after Orthopaedic Surgery: A longitudinal follow-up (GOLF) study protocol.

Aims: The primary aim of this prospective, multicentre study is to describe the rates of returning to golf following hip, knee, ankle, and shoulder arthroplasty in an active golfing population. Secondary aims will include determining the timing of return to golf, changes in ability, handicap, and mobility, and assessing joint-specific and health-related outcomes following surgery. Methods: This is a multicentre, prospective, longitudinal study between the Hospital for Special Surgery, (New York City, New York, USA) and Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, (Edinburgh, UK). Both centres are high-volume arthroplasty centres, specializing in upper and lower limb arthroplasty. Patients undergoing hip, knee, ankle, or shoulder arthroplasty at either centre, and who report being golfers prior to arthroplasty, will be included. Patient-reported outcome measures will be obtained at six weeks, three months, six months, and 12 months. A two-year period of recruitment will be undertaken of arthroplasty patients at both sites. Conclusion: The results of this prospective study will provide clinicians with accurate data to deliver to patients with regard to the likelihood of return to golf and timing of when they can expect to return to golf following their hip, knee, ankle, or shoulder arthroplasty, as well as their joint-specific functional outcomes. This will help patients to manage their postoperative expectations and plan their postoperative recovery pathway.

The Efficacy of Telehealth for the Treatment of Spinal Disorders: Patient-Reported Experiences During the COVID-19 Pandemic.

BACKGROUND: The use of telehealth saw a rapid surge during the early months of the COVID-19 pandemic. There remains little data on how effectively telehealth replicates traditional office visits in the treatment of spinal disorders and how telehealth is perceived by patients with spinal disorders. QUESTIONS/PURPOSES: We sought to evaluate patient satisfaction with telehealth visits as a platform for delivering care for the treatment of spinal pathology. METHODS: Patients undergoing a telehealth visit with providers specializing in the treatment of spinal disorders (one surgeon and two physiatrists) were provided with an anonymous, online survey. Data on patient satisfaction, effectiveness of the telehealth visit (in comparison with in-person visits), and clarity of communication were collected through 5-point Likert scales; visit characteristics and free-text responses were also collected. RESULTS: Eighty-four patients responded to the survey. Their attitudes were largely positive, with an overall mean patient satisfaction score of 4.79. Patients gave high scores for clarity of communication during the visit, and for satisfaction with the formulation of treatment plans and their ability to ask questions, they gave the lowest scores to the effectiveness of telemedicine in replacing an in-person visit and ease of interface navigation. CONCLUSIONS: The high overall patient satisfaction reported by our patients seeking care for a spinal pathology supports the growing body of evidence promoting the use of telehealth for orthopedic care. Further research is needed in a standardized telehealth examination of patients with spinal disorders.

The Impact of Body Mass Index on Fluoroscopy Time During Lumbar Epidural Steroid Injection; A Multicenter Cohort Study.

Objective: This study aimed to assess the relationship between BMI and fluoroscopy time during lumbar epidural steroid injections (LESIs) performed for lumbosacral radicular pain. Design: Multicenter retrospective cohort study. Setting: Three academic, outpatient pain treatment centers. Subjects: Patients who underwent fluoroscopically guided LESI. Methods: Mean and standard deviation (SD) fluoroscopy time were compared between patients with normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2) BMI. Statistical significance was set at P=0.01 due to multiple comparisons. Results: A total of 2,930 procedure encounters were included, consisting of 598 interlaminar LESIs and 2,332 transforaminal LESIs. Fluoroscopy time was significantly longer in the obese patients compared to normal and overweight patients during interlaminar LESI (P < 0.01). Fluoroscopy time was significantly longer with each increasing BMI category in during transforaminal LESI (P < 0.01). These relationships remained when a trainee was involved (P < 0.01; P<0.01), during repeat injections (P < 0.01; P < 0.01), and during bilateral transforaminal LESIs (P < 0.01). While longer fluoroscopy times were required in high BMI categories during L5-S1 transforaminal LESI (P < 0.01), there was no relationship between fluoroscopy time and BMI during L4-L5 and S1 transforaminal LESI (P = 0.02; P = 0.13). Fluoroscopy time during interlaminar LESI compared to transforaminal LESI was significantly lower within all BMI categories (all P<0.01). Conclusions: The findings of this study indicate that fluoroscopy time is increased during interlaminar LESIs and during L5-S1 transforaminal LESIs in patients who are obese. These relationships are not affected by injection number, performance of bilateral injections, or trainee involvement. Further study is needed to determine if this increase in fluoroscopy time is indicative of a clinically significant associated increase in radiation dose.

Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Cervical Interlaminar Epidural Steroid Injections?

BACKGROUND: The challenge of obtaining medical imaging in individuals with higher body mass index (BMI) is described, but there is minimal data regarding the relationship between BMI and fluoroscopy time during cervical interlaminar epidural steroid injection (CIESI). OBJECTIVE: To determine the relationship between BMI and fluoroscopy time during CIESI. METHODS: Retrospective cohort study of patients who underwent fluoroscopically guided CIESI between January 2014 and February 2015 at an academic pain medicine center. Fluoroscopy time data were collected. Comparisons based on analysis of variance were made between patients with normal (<25.0 kg/m 2 ), overweight (25.0-29.9 kg/m 2 ), and obese (≥30.0 kg/m 2 ) BMI. RESULTS: Of 399 procedure encounters, 366 had documented BMI and fluoroscopy time data and were included for analysis. Mean age (± SD) in this cohort was 53 ± 13 years, including 189 females (52%) and 205 first-time injections. Mean fluoroscopy time for all injections was 18 ± 10 seconds. Separated by categorical BMI class, the mean fluoroscopy time was 18 ± 9 seconds for normal weight patients, 17 ± 10 seconds for overweight patients, and 20 ± 11 seconds for obese patients, respectively. Post hoc analysis showed that fluoroscopy time was significantly longer only in obese compared with overweight patients ( P = 0.02). Trainee involvement and first-time vs repeat injection did not significantly alter fluoroscopy time ( P = 0.17 and P = 0.12, respectively). CONCLUSIONS: The findings of this study indicate that BMI does not appear to have a clinically significant impact on fluoroscopy time during cervical interlaminar epidural steroid injection procedures. Future study is needed to directly quantify radiation exposure in patients and practitioners, as well as the associated health risk.

Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Sacroiliac Joint Injection? A Multicenter Cohort Study.

OBJECTIVE: To determine the relationship between BMI and fluoroscopy time during intra-articular sacroiliac joint (SIJ) injections performed for a pain indication. DESIGN: Multicenter retrospective cohort study. SETTING: Three academic, outpatient pain treatment centers. SUBJECTS: Patients who underwent fluoroscopy guided SIJ injection with encounter data regarding fluoroscopy time during the procedure and body mass index (BMI). MAIN OUTCOME MEASURE: Median and 25-75% Interquartile Range (IQR) fluoroscopy time. RESULTS: 459 SIJ injections (350 patients) were included in this study. Patients had a median age of 57 (IQR 44, 70) years, and 72% were female. The median BMI in the normal weight, overweight, and obese groups were 23 (IQR 21, 24), 27 (IQR 26, 29), and 35 (IQR 32, 40), respectively. There was no significant difference in the median fluoroscopy time recorded between these BMI classes (p = 0.45). First-time SIJ injection (p = 0.53), bilateral injection (p = 0.30), trainee involvement (p = 0.47), and new trainee involvement (trainee participation during the first 2 months of the academic year) (p = 0.85) were not associated with increased fluoroscopy time for any of the three BMI categories. CONCLUSIONS: Fluoroscopy time during sacroiliac joint injection is not increased in patients who are overweight or obese, regardless of whether a first-time sacroiliac joint injection was performed, bilateral injections were performed, a trainee was involved, or a new trainee was involved.

Cost minimization in treatment of adult degenerative scoliosis.

OBJECT: Back pain is an increasing concern for the aging population. This study aims to evaluate if minimally invasive surgery presents cost-minimization benefits compared with open surgery in treating adult degenerative scoliosis. METHODS: Seventy-one patients with adult degenerative scoliosis received 2-stage, multilevel surgical correction through either a minimally invasive spine surgery (MIS) approach with posterior instrumentation (n = 38) or an open midline (Open) approach (n = 33). Costs were derived from hospital and rehabilitation charges. Length of stay, blood loss, and radiographic outcomes were obtained from electronic medical records. Functional outcomes were measured with Oswestry Disability Index (ODI) and visual analog scale (VAS) surveys. RESULTS: Patients in both cohorts were similar in age (Age(MIS) = 65.68 yrs, Age(Open) = 63.58 yrs, p = 0.28). The mean follow-up was 18.16 months and 21.82 months for the MIS and Open cohorts, respectively (p = 0.34). MIS and Open cohorts had an average of 4.37 and 7.61 levels of fusion, respectively (p < 0.01). Total inpatient charges were lower for the MIS cohort ($269,807 vs $391,889, p < 0.01), and outpatient rehabilitation charges were similar ($41,072 vs $49,272, p = 0.48). MIS patients experienced reduced length of hospital stay (7.03 days vs 14.88 days, p < 0.01) and estimated blood loss (EBL) (EBL(MIS) = 470.26 ml, EBL(Open)= 2872.73 ml, p < 0.01). Baseline ODI scores were lower in the MIS cohort (40.03 vs 48.04, p = 0.03), and the cohorts experienced similar 1-year improvement (ΔODI(MIS) = -15.98, ΔODI(Open) = -21.96, p = 0.25). Baseline VAS scores were similar (VAS(MIS) = 6.56, VAS(Open)= 7.10, p = 0.32), but MIS patients experienced less reduction after 1 year (ΔVAS(MIS) = -3.36, ΔVAS(Open) = -4.73, p = 0.04). Preoperative sagittal vertical axis (SVA) were comparable (preoperative SVA(MIS) = 63.47 mm, preoperative SVA(Open) = 71.3 mm, p = 0.60), but MIS patients had larger postoperative SVA (postoperative SVA(MIS) = 51.17 mm, postoperative SVA(Open) = 28.17 mm, p = 0.03). CONCLUSIONS: Minimally invasive surgery demonstrated reduced costs, blood loss, and hospital stays, whereas open surgery exhibited greater improvement in VAS scores, deformity correction, and sagittal balance. Additional studies with more patients and longer follow-up will determine if MIS provides cost-minimization opportunities for treatment of adult degenerative scoliosis.

The pearls and pitfalls of magnetic resonance imaging for the spine.

Musculoskeletal imaging of the spine can be an invaluable tool to inform clinical decision making in patients with spinal pain. An understanding of the technology involved in producing and interpreting high-resolution images produced from magnetic resonance imaging (MRI) of the human spine is necessary to better appreciate which sequences can be used for, or tailored to, individual patients and their conditions. However, there is substantial variability in the clinical meaningfulness of some MRI findings of spinal tissues. For example, normal variants can often mimic significant musculoskeletal pathology, which could increase the risk of misinformed clinical decisions and, even worse, poor or adverse outcomes. This clinical commentary will highlight some of the pearls and pitfalls of MRI for the cervical, thoracic, and lumbar regions, and include cases to illustrate some of the common imaging artifacts and normal variants for MRI of the spine.

In vivo noninvasive evaluation of abnormal patellar tracking during squatting in patients with patellofemoral pain.

BACKGROUND: Patellofemoral pain syndrome is one of the most common knee problems and may be related to abnormal patellar tracking. Our purpose was to compare, in vivo and noninvasively, the patellar tracking patterns in symptomatic patients with patellofemoral pain and those in healthy subjects during squatting. We tested the hypothesis that patients with patellofemoral pain exhibit characteristic patterns of patellar tracking that are different from those of healthy subjects. METHODS: Three-dimensional patellar kinematics were recorded in vivo with use of a custom-molded patellar clamp and an optoelectronic motion capture system in ten healthy subjects and nine subjects with patellofemoral pain. The position of osseous knee landmarks was digitized while subjects stood upright, and then patellofemoral kinematics were recorded during squatting. The tracking technique was validated with use of both in vitro and in vivo methodologies, and the average absolute error was <1.2 degrees and <1.1 mm. RESULTS: At 90 degrees of knee flexion, the patella showed lateral spin (the distal pole of the patella rotated laterally) in subjects with patellofemoral pain (mean and standard deviation, -10.13 degrees +/- 2.24 degrees) and medial spin in healthy subjects (mean, 4.71 degrees +/- 1.17 degrees) (p < 0.001). At 90 degrees of knee flexion, the patella demonstrated significantly more lateral translation in subjects with patellofemoral pain (mean, 5.05 +/- 3.73 mm) than in healthy subjects (mean, -4.93 +/- 3.93 mm) (p < 0.001). CONCLUSIONS: Kinematic differences between healthy subjects and subjects with patellofemoral pain were demonstrated through a large, dynamic range of knee flexion angles. Increased lateral patellar translation and lateral patellar spin in subjects with patellofemoral pain suggest that the patella is not adequately balanced during functional activities in this group. Prospective studies are needed to identify when patellofemoral pain-related changes begin to occur and to determine the risk for the development of patellofemoral pain in individuals with abnormal kinematics.